^^T^\ 


Columbia  Wlnibtxiit^ 
in  rtie  Citj»  of  ^eto  gotk 

COLLEGE  OF  PHYSICIANS 
AND  SURGEONS 


^ 


303 


Jfrom  ti)c  ULihtatp  of 

Br.  Cijrisftian  13.  Herter 

Bonateb  hp 
iWrsi.  I^cnrp  B.  Bakin 

1920 


A  TREATISE 


ORTHOPEDIC  SURGERY 


BY 


EOYAL  WHITMAN,  M.D. 


IKSTRUCTOE     IN    ORTHOPEDIC    SURGEEY    IN    THE    COLLEGE    OF    PHYSICIANS    AND    SURGEONS    OF    COLUMBIA 

UNIVERSITY,    NEW    YORK  ;    AS-SOCIATE    SURGEON    TO    THE    HOSPITAL    FOR    RUPTURED    AND 

crippled;    ORTHOPEDIC  SURGEON  TO  THE  HOSPITAL  OF  ST.  JOHN'S  GUILD; 

CHIEF  OF    THE    ORTHOPEDIC    DEPARTMENT    OF  THE 

VANDERBILT    CLINIC. 

MEMBER    OF    THE    ROYAL    COLLEGE    OF    SURGEONS    OF    ENGLAND;    MEMBER    AND  SOMETIME    PRESIDENT  OF 

THE    AMERICAN    ORTHOPEDIC    ASSOCIATION  ;     CORRESPONDING    MEMBER    OF    THE    BRITISH 

ORTHOP.EDIC  SOCIETY  ;    MEMBER  OF  THE  NEW  YORK  SURGICAL  SOCIETY',   ETC. 


SECOND  EDITION,  REVISED  AND  ENLARGED 


ILLUSTRATED    WITH    FIVE    HUNDRED  AND  SEVEN    ENGRAVINGS 


LEA    J5R0THERS    &   CO. 

PHILADELPHIA     AND     N  p:  W     YORK 


Entered  according  to  the  Act  of  Congress,  in  the  year  1903,  b}' 

LEA    BROTHERS    &    CO., 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


noRNAN,   PRINTER. 


TO 

VIRGIL  P.  GIBNEY,  M.D,  LL.D. 

THIS    VOLUME    IS    INSCRIBED 

AS    A    TOKEN    OF    FRIENDSHIP    ASSURED    BY   LONG   ASSOCIATION 

AND    OF    APPRECIATION    OF    HIS    EFFORTS' 

FOR    THE    ADVANCEMENT    OF 

ORTHOPEDIC   SURGERY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseonorthop1903whit 


PREFACE  TO  THE  SECOND  EDITION. 


The  author  has  utilized  the  opportuuity  offered  by  the  early 
exhaustion  o£  the  first  edition  to  thoroughly  revise  the  book; 
and  he  trusts  that  in  its  present  form  it  fairly  represents  this 
department  of  medicine  at  the  date  of  issue.  The  consideration  of 
new  subjects,  the  more  extended  description  of  others,  and  the 
addition  of  illustrative  figures  have  resulted  in  a  material  enlarge- 
ment of  the  book,  but  the  general  characteristics  of  the  first  edition 
have  been  retained. 

283  Lexington  Avenue,  New  York,  October,  1903. 


FROM  THE  PREFACE  TO  THE  FIRST  EDITION. 


In  the  preparation  of  this  volume  it  has  been  the  purpose  of 
the  author  to  present  as  adequately  as  might  be  the  practice  of 
Orthopedic  Surgery  of  the  present  day.  The  student  of  this 
subject  is  especially  concerned  with  the  mechanics  of  the  human 
machine,  with  its  development,  with  its  capacity  at  different 
periods  of  life  and  under  varying  conditions,  and  with  those 
affections  that  lead  to  deformity  or  that  otherwise  impair  its  use- 
fulness. He  is  concerned,  moreover,  not  only  with  the  local  and 
immediate  effects  of  disease  or  disability,  but  with  its  general 
influence  upon  the  entire  mechanism,  and  with  its  ultimate  con- 
sequences as  well. 

Orthopedic  Surgery  occupies  a  broad  field  and  one  of  very 
great  and  general  interest.  Its  most  distinctive  advance  in  recent 
years  has  been  toward  the  prevention  of  deformity,  an  advance 


vi  PEE  FACE. 

that  has  been  made  possible  by  the  better  understanding  o£  its 
predisposing  and  exciting  causes.  As  a  natural  consequence, 
treatment  has  become  more  direct,  more  simple,  and  more  effec- 
tive. It  has  been  the  purpose  of  the  author  to  emphasize  this 
aspect  of  the  subject,  which  is  of  the  greatest  importance  to  the 
general  practitioner,  who  so  often  has  the  opportunity  to  recognize 
disease  or  disability  in  its  incipiency,  when  its  progress  may  be 
checked  by  timely  treatment. 

He  has  endeavored  to  present  Orthopedic  Surgery  as  far  as 
possible  objectively,  and  in  a  manner  that  has  proved  acceptable 
to  students  and  practitioners  in  clinical  teaching.  Thus  the 
selection  of  each  subject  and  the  space  that  has  been  allotted  to 
it  has  been  determined  primarily  by  its  relative  importance  in 
the  actual  work  of  orthopedic  clinics.  He  has  been  at  some 
pains,  also,  to  outline  methods  of  examination,  to  explain  the 
phenomena  of  the  symptoms  and  so  to  describe  and  to  illustrate 
the  causes  and  effects  of  disease  and  disability  as  to  indicate,  in 
natural  sequence,  the  principles  of  treatment ;  but  the  particular 
methods  of  the  application  of  these  principles,  which  have  been 
described  in  detail,  are  always  those  that  have  been  tested  by 
personal  experience. 

Although  this  book  is  designed  particularly  for  students  and 
practitioners  of  medicine,  the  author  has  included  statistical  and 
other  data  which  he  hopes  may  prove  of  interest  to  his  fellow- 
workers  in  this  special  field. 

The  author  desires  to  express  his  obligation  to  the  gentlemen 
who  have  assisted  him  in  the  collection  of  statistics,  and  other- 
wise, whose  names  are  mentioned  in  the  text ;  to  Dr.  L.  W.  Ely 
and  to  Mr,  W.  P.  Agnew  for  timely  photographs,  and  especially 
to  the  Trustees  of  the  Hospital  for  Ruptured  and  Crippled,  for 
the  facilities  that  have  been  afforded  him  in  the  preparation  of 
this  work. 


CONTEXTS. 


CHAPTER  I. 


TUBERCULOUS    DISEASE    OF    THE    SPINE. 

PAGE 

Description  — Pathology  — Etiology  — Statistics  — General  prognosis  — 
Symptoms — Physical  examination — Contour  and  flexibility  of  the 
spine — Divisions  of  the  spine — Landmarks — The  differential  diagno- 
sis of  disease  in  the  lower,  middle,  and  upper  regions  of  the  spine — 
Treatment  by  horizontal  fixation  and  OA'erexten.sion — by  braces —  . 
by  plaster  jackets — by  other  means.  The  selection  and  adaptation 
of  treatment  for  disease  of  the  different  regions  of  the  spine.  The 
complications  of  tuberculous  disease  of  the  spine — Abscess — course 
■ — symptoms — treatment.  Paralysis — course — symptoms — treat- 
ment. Forcible  correction  of  deformity — (Calot's  operation) — 
Gradual  correction  of  deformity — Recurrence  of  Disease — Second- 
ary deformities — Recapitulation.  ......        17 

CHAPTER  II. 

NON-TUBERCULOUS    AFFECTIONS    OF    THE    SPINE. 

Syphilis — Malignant  disease — Osteomyelitis,  acute  and  chronic — Actino- 
mycosis — Injury  — Traumatic  spondylitis  — Rhachitic  spine — Ty- 
phoid spine — Gonorrhoeal  arthritis  of  the  spine — Arthritis — Spon- 
dylitis defonnans,  varieties — Osteitis  deformans — Neurotic  spine — 
Hysterical  spine  — Pain  in  the  back  — Spondylolisthesis — Sciatic 
scoliosis — Disease  and  injury  at  the  sacroiliac  articulation       .  .      129 

CHAPTER  III. 

LATERAL    CURVATURE    OF    THE    SPINE. 

Description — habitual  and  fixed  deformity,  rotation  and  lateral  devia- 
tion. Pathology — Etiology  — Statistics  — Varieties  — Distribution 
and  effects  of  deformity — Symptoms — Diagnosis — Prognosis — Pre- 
vention of  deformity — Desks,  chairs — Principles  of  treatment — 
Treatment  — by  exercises  —  general  exercises  —  heavy  exercises  — 
special  exercises — Supports.  Forcible  correction  of  deformity  — 
Adjuncts  in  treatment — Duration  of  treatment      ....      149^ 

CHAPTER  IV. 

DEFORMITIES    OF   THE   SPINE    (CONTINUED).       DEFORMITIES   OF   THE   CHEST' 
FUNCTIONAL    PATHOGENESIS    OF    DEFORMITY. 

Varietiesin  contour  of  the  spine — The  round  and  the  flat  back — Kyphosis 
— Lordo.sis  — Treatment  — Congenital   elevation  of  the  scapula  — 


CONTENTS. 


Absence  of  vertebrse — Flat  chest — Pigeon  chest — Funnel  chest — 
Minor  deformities — Absence  of  ribs — DefectiA-e  formation  of  the 
pectoral  muscles — Absence  or  defect  of  the  cla^-icle — Acquired  lux- 
ation or  subluxation  of  the  cla^dcle — Asj'mmetrical  de^-elopment — 
Tables  of  height,  weight,  and  circumference  of  the  chest — Func- 
tional pathogenesis  of  deformity — (Wolff's  law) — Atroph}-  of  bone   .    223 

CHAPTER  V. 

TUBERCULOUS    DISEASE    OF    THE    BONES    AND    JOINTS. 

Predisposition — Mode  of  infection — Latent  tuberculosis — Local  predis- 
position— Statistics — -distribution  of  disease — location — side  affected 
— sex — age.  Patholog}' — Varieties  of  disease — synovial — arbores- 
cent sjaiovial  foi-m — lipoma  arborescens — rice  bodies — caries  sicca — 
Progress  and  method  of  repair — Prognosis — Treatment — operative 
and  mechanical — h\  drugs — local  applications — X-ray — Active  and 
passive  congestion — venous  stasis  (Bier's  treatment)      .  .  .      243 

CHAPTER  VI. 

NON-TUBERCULOUS    DISEASES    OP    THE    JOINTS. 

Syphilitic  disease  of  joints — Gonorrhoea!  arthritis — Other  forms  of  in- 
fectious arthritis — Acute  epiplwsitis — acute  osteomyelitis — Sub- 
acute osteomyelitis — Osteoarthritis  and  rheumatoid  arthritis — Va- 
rieties — Treatment  — Still's  disease  — Hasmophilia — Haemarthrosis 
— Scorbutus — Charcot's  disease — Other  forms  of  arthropathy — An- 
chylosis   ...........     263 

CHAPTER  VII. 

TUBERCULOUS    DISEASE    OF    THE    HIP-JOINT. 

Pathology — Statistics — Symptoms— Physical  signs,  distortion,  apparent 
lengthening,  apparent  shortening.  Causes  of  distortion — Atrophy — 
Causes  of  actual  shortening  — Measurements  - — Lovett's  table  — 
Kingslej-'s  table — Explanation  of  physical  signs — Differential  diag- 
nosis —  Principles  of  treatment  — The  traction  hip  brace  — The 
Thomas  brace — The  plaster  bandage — Various  methods  of  reducing 
deformity^Comparison  of  methods  of  treatment — The  long  hip 
splint — Other  forms  of  apparatus — Bilateral  hip  disease — Hip  dis- 
ease in  infancy — Hip  disease  in  adult  life— Abscess — statistics — 
treatment  — Operative  treatment — exploration — excision — reduc- 
tion of  resistant  deformity — Prognosis,  mortality,  functional  results 
— Secondary  deformities  of  hip  disease — Treatment — Final  results   .    291 

CHAPTER  VIII. 

NON-TUBERCULOUS    AFFECTIONS    OF    THE    HIP-JOINT. 

Statistics — Traumatisms  at  the  hip — Acute  infectious  arthritis — Sub- 
acute arthritis — Spontaneous  dislocation — Gonorrhoeal  arthritis — 
Extra-articular  disease — Malignant  disease  at  the  hip-joint — Cysts 
of  the  femur — -Arthritis  deformans       ......      391 


CONTENTS.  ix 

CHAPTER  IX. 

TUBERCULOUS    DISEASE    OF    THE    KNEE-JOINT. 

PAGE 

Pathology — Etiology — Statistics — Symptoms,  primary  and  secondaiy 
distortions — Shortening  and  lengthening — Diagnosis — Differential 
diagnosis — Treatment — Reduction  of  deformity — Forms  of  braces 
— Accessories  in  treatment — Extra-articular  disease — Abscess — 
Operative  treatment — arthrectomy — excision,  amputation — Prog- 
nosis— mortality — functional  results — General  conclusions  .      399 

CHAPTER  X. 

NON-TUBERCULOUS    AFFECTIONS    OF    THE    KNEE-JOINT. 

Injury  in  childhood — Synovitis — Infectious  arthritis — Osteoarthritis — 
Prepatellar  bursitis — Pretibial  bursitis — Injury  of  tibial  tubercle — 
Bursse  and  cysts  in  the  popliteal  region — Internal  derangement  of 
the  knee-joint — Acquired  genu  recurvatum — Congenital  genu  recur- 
vatum — rudimentary  or  absent  patella — Congenital  displacement 
of  patella — Slipping  patella — Elongation  of  the  ligamentum  patellae 
— Snapping  knee — Congenital  contraction  at  the  knee — General 
contractions  .........      427 

CH.\PTER  XI. 

DISEASES    AND    INJURIES    OF    THE    ANKLE-JOINT. 

Tuberculous  disease — Pathology — Etiology — Statistics — Symptoms — 
Diagnosis — Treatment — Prognosis — Tuberculous  disease  of  the 
tarsus — Statistics — Treatment — Sprain  of  the  ankle — Chronic  sprain 
— Tenosynovitis — Other  affections  of  the  ankle-joint      .  .  .     440 

CHAPTER  XII. 

DISEASES    AND    INJURIES    OF    THE    ARTICULATIONS    OF    THE 
UPPER    EXTREMITY. 

Tuberculous  disease  of  the  shoulder-joint — Pathology — Statistics — 
Symptoms — Treatment — Prognosis — Tuberculous  disease  of  the 
elbow-joint — Pathology— Statistics — Symptoms— Treatment — Prog- 
nosis— Tuberculous  disease  of  the  wrist-joint — Syinptoms — Treat- 
ment— Prognosis — Spina  ventosa — Periarthritis  at  the  shoulder- 
joint — Chronic  bursitis  at  the  shoulder — Sprain  of  the  wrist — 
Acute  and  chronic  tenosynovitis  at  the  wrist         ....      457 

CHAPTER  XIII. 

DEFORMITIES    OF    THE    UPPER    EXTREMITY. 

Congenital  dislocation  of  the  shoulder — Treatment — Obstetrical  paral- 
ysis—Recurrent dislocation  of  the  shoulder — Congenital  deformities 
of  the  elbow — Cul)itus  valgus — C!ubitus  varus — Subluxation  of  the 
wrist — Congenital  deformities  at  the  wrist — Club-hand — Varieties — ■ 


CONTENTS. 


— Treatment — Club-hand  associated  with  defective  development — 
Congenital  contraction  of  the  fingers — Webbed  fingers — Congenital 
displacement  of  phalanges — Trigger  finger — Mallet  finger — Base- 
ball finger — Dupuytren's  contraction  .....      472 


CHAPTER  XIV. 

CONGENITAL    AND    ACQUIRED    AFFECTIONS    LEADING    TO    GENERAL 
DISTORTIONS. 

Rhachitis — Etiology — Pathology — Symptoms,  deformities — Prognosis — 
Treatment — "  Late  rickets" — Chondrodystrophia — Infantile  scor- 
butus— Fragilitas  ossium — Osteomalacia — Osteitis  deformans — 
Secondary  hypertrophic  osteo-arthropathy — Acromegalia       .  .      486 


CHAPTER  XV. 

CONGENITAL    DISLOCATION    OF    THE    HIP    AND    COXA    VARA. 

Congenital  dislocation  of  the  hip-joint — Statistics — Pathology — Etiology 
— Symptoms,  unilateral,  bilateral — Anterior — Supracotyloid — Diag- 
nosis— Differential  diagnosis — Treatment — the  Lorenz  operation — 
Details  and  modifications — Prognosis — Treatment  of  older  subjects 
— Treatment  in  infancy — The  open  operation — Arthrotomj^ — the 
intermediate  operation — secondary  osteotomj' — Review  of  treat- 
ment— Congenital  subluxation  of  the  hip — Snapping  hip — Palliative 
treatment — Coxa  vara — Pathology — Etiology — Statistics — Symp- 
toms, unilateral,  bilateral — Diagnosis — Treatment — mechanical — 
operative — Forcible  abduction — Osteotomy — Cuneiform — Linear — 
Fracture  of  the  neck  of  the  femur — Traumatic  separation  of  the 
epiphysis  of  the  head  of  the  femur — Fracture  in  adult  life — Coxa 
valga       .......  ....     502 

CHAPTER  XVI. 

DEFORMITIES   OF    THE    BONES    OF    THE    LOWER    EXTREMITY. 

Bow-leg — Knock-knee — Statistics — Etiology — The  outgrowth  of  defor- 
mity— Genu  valgum — Description — Attitudes — Secondary  defor- 
mities— Gait — Unilateral  deformity — Patholog}' — Treatment — ex- 
pectant— mechanical — operative — Genu  varum,  varieties — Symp- 
toms— Treatment — Expectant —  mechanical — operative — Anterior 
bow-leg — General  rhachitic  distortions        .....     553 

CHAPTER  XVII. 

DISEASES    OF    THE    NERVOUS    SYSTEM. 

Acute  anterior  poliomyelitis — Pathology — Etiology — Statistics — Symp- 
toms— Diagnosis — Prognosis — Causes  of  Deformity — Deformit}^  in 
various  regions — Subluxation — Retardation  of  growth — Principles 
of  Treatment — Treatment,  mechanical,  operative   ....      583 


CONTENTS.  xi 

CHAPTER  XVIII. 

DISEASES    OF    THE    NERVOUS    SYSTEM    (CONTINUED). 

PAGE 

Cerebral  paralysis  of  childhood — Description — Distribution — Etiology — 
Pathology — Symptoms — Congenital  paralysis — Acquired  paralysis 
— Hemiplegia — Paraplegia — Treatment — Prognosis — Spastic  spinal 
paraplegia — Progressive  muscular  atroph}' — Varieties — Symptoms 
— Hereditary  ataxia — Neuritis — Hysterical  and  functional  affec- 
tions of  the  joints — "Hysterical"  hip — Differential  diagnosis — 
"  Hysterical"  deformities — "  Hysterical"  club-foot — "  Hy.sterical" 
scoliosis — Neurotic  joints  ........      606 

CHAPTER  XIX. 

CONGENITAL    AND    ACQUIRED    TORTICOLLIS. 

Description — Statistics — Congenital  torticollis — Etiology — Hsematoma 
of  the  sternomastoid  muscle  —  Acquired  torticollis — Varieties — 
Acute  torticollis — Etiology — Symptoms — Diagnosis — Treatment  of 
chronic  torticollis — mechanical,  operative  —  Treatment  of  acute 
torticollis  —  Spasmodic  torticollis — Etiology  —  Pathology  —  Treat- 
ment— Exceptional  forms  of  torticollis — paralytic — diphtheritic — 
cervical  opisthotonos,  rhachitic — ocular — psychical        .  .      625 

CHAPTER  XX. 

DISABILITIES    AND    DEFORMITIES    OF    THE    FOOT. 

General  description  of  the  foot  and  of  its  functions,  the  arches,  the  foot 
as  a  passive  support,  in  activity — Improper  postures — Movements 
— Function  of  the  muscles — Strength  of  the  muscles — The  foot  as  'a, 
mechanism — The  weak  foot  or  so-called  flat-foot —  Description — 
Anatomy — Pathology — Etiologj^ — Statistics — Symptoms — Diagno- 
sis— Varieties — Weak  foot  in  childhood — Treatment,  preventive — 
Exercises — Support — Construction  of  brace — The  rigid  weak  foot — 
Forcible  correction  of  deformity — Subsequent  treatment — Adjuncts 
in  treatment — Operative  treatment  .  .  .  .647 

CHAPTER  XXI. 

DISABILITIES    AND    DEFORMITIES    OF    THE    FOOT    (CONTINUED). 

The  hollow  foot — Varieties  and  treatment — Anterior  metatarsalgia — 
Morton's  neuralgia  —  Etiology  —  Treatment  —  Achillobursitis  — 
Strain  of  the  tendo  Achillis — Calcaneobursitis — Plantar  neuralgia 
— Erythromelalgia — Hallux  rigidus — Painful  great  toe — Hallux 
varus — Pigeon  toe — Hallux  valgus — Hammer  toe — Overlapping 
toes — Fracture  of  metatarsus — Exostoses — Displacement  of  the 
peronoi  tendons — Shoes,  effects  of  improper  shoes — Demonstra- 
tion of  the  proper  shoe — Socks    .  .  .  .  699 


xii  CONTENTS. 

CHAPTER  XXII. 

DEFORMITIES    OP    THE    FOOT. 

PAGE 

Talipes — Description — Varieties — Statistics  of  talipes,  congenital  and 
acquired — Relative  frequency  of  the  different  varieties — Congenital 
talipes — Etiologj^ — Anatomj^ — Symptoms — Principles  of  treatment 
of  infantile  club-foot — Treatment — mechanical — by  plaster  ban- 
dage— bj^  braces — restoration  of  function — supervision — Treatment 
in  older  subjects — forcible  manual  correction — tenotomj' — Wolff's 
treatment,  reduction  of  deformity  by  wrenches — Phelps'  operation 
— Operations  on  the  bones — Astragalectomy — Osteotomy — Me- 
chanical treatment^ — Other  varieties  of  congenital  talipes — varus 
— equinus —  calcaneus —  valgus —  equinovalgus  —  calcaneovalgus — 
calcaneovarus — equinocavus — valgocavus — Congenital  talipes  as- 
sociated with  defective  development — with  absence  of  fibula — with 
absence  of  tibia — with  defective  formation  of  the  foot — Constricting 
bands — Congenital  amputation — Congenital  oedema — Spina  bifida 
and  talipes       .  .  ........    733 

CHAPTER  XXIII. 

DEFORMITIES    OP    THE    FOOT    (CONTIXUEd). 

Acquired  talipes — Etiolog}'— Diagnosis — Talipes  equinus — Description — 
Etiology — Symptoms — Treatment — mechanical — operative  Talipes 
calcaneus — Description,  development  of  deformity — Symptoms — 
Treatment — mechanical,  operative — Talipes  calcaneo  varus  and 
calcaneovalgus — Talipes  equinovarus  and  talipes  equinovalgus — 
Talipes  valgus — Traumatic  valgus — Other  varieties  of  acquired 
talipes — Tendon  transplantation  in  the  treatment  of  paralytic  talipes 
— Tendon  transplantation  and  arthrodeses — Tendon  splicing — 
Arthrodesis  and  other  procedures         ......      794 


ORTHOPEDIC  SURGERY. 


CHAPTER    I. 

TUBEECULOUS  DISEASE  OF  THE  SPINE. 

Synonym.     Pott's  disease. 

Pott's  disease  is  a  chronic  destructive  ostitis  of  the  bodies  of 
the  vertebrae,  the  anterior  or  weight-supporting  portion  of  the 
spinal  column.  As  the  disease  progresses  the  spine  bends  at  the 
weakened  point,  and  the  upper  part,  sinking  downward  and  for- 
ward, throws  into  relief  the  spinous  processes  at  the  seat  of  the 
disease ;  thus  an  angular  posterior  projection  is  formed.  It  is  called 
Pott's  disease  because  such  deformity,  slow  in  formation,  accom- 
panied by  pain  and  sometimes  by  paralysis,  was  first  described 
accurately  by  Percival  Pott,  in  1779.  Angular  deformity  is, 
however,  simply  the  evidence  of  destruction  of  a  portion  of  the 
anterior  part  of  the  vertebral  column.  Thus  it  might  be  the 
result  of  fracture,  or  of  the  erosion  of  an  aneurism,  or  of  malig- 
nant disease,  or  syphilis,  or  other  pathological  process;  but 
deformity  from  such  causes  is  not  now  included  under  Pott's  dis- 
ease, nor  is  the  term  now  synonymous  with  deformity.  In  the 
modern  sense  it  signifies  tuberculous  disease  of  the  bodies  of  the 
vertebrae,  of  which  the  early  symptoms  may  be  detected  and  of 
which  the  deforming  effects  may  be  checked  and  even  prevented 
by  proper  treatment. 

The  compression  and  collapse  of  the  affected  parts  cause  the 
characteristic  angular  projection  at  the  seat  of  the  disease  (Fig.  2). 
If  one  vertebral  body  is  destroyed  the  projection  will  be  sharp ;  if 
several  are  implicated  it  will  be  less  angular,  and  if  one  side  of  a 
body  breaks  down  before  the  other  there  may  be  a  lateral  as  well 
as  a  posterior  distortion. 

The  size  of  the  deformity  and  its  effect  upon  the  individual 
depend  in  great  degree  upon  its  situation.  If  the  disease  is  at 
either  extremity  of  the  spine  the  angular  projection  must  be  small, 
because  so  little  of  the  column  remains  beyond  the  destructive 

2 


18 


ORTHOPEDIC  8UBQEBY. 


Fig.  1. 


process ;  in  other  words,  the  area  of  the  spine  directly  involved 
in  the  deformity  is  small  compared  to  that  which  is  free  from  dis- 
ease (Fig.  5).  But  if  the  middle  of  the  spine  is  affected,  the 
opportunity  for  deformity  is  great,  because  the  entire  column  may 
enter  into  the  formation  of  the  angular  kyphosis.  In  such  cases 
the  internal  organs  are  compressed  and  the  effect  upon  the  vital 
mechanism  is  disastrous  (Fig.  23). 

Pott's  disease,  as  contrasted  with  tuberculosis  of  other  bones 
and  joints,  is  peculiar  in  that  it  is  concealed  from  view,  in  that 
direct  surgical  intervention  is  of  compara- 
tively little  avail,  in  that  it  lies  in  close 
proximity  to  important  parts,  the  spinal  cord 
behind  and  the  vital  organs  in  front,  and, 
finally,  in  that  the  effects  of  the  disease  and 
deformity  are  not  limited  to  the  parts  di- 
rectly involved,  but  influence,  to  a  greater 
or  less  degree,  the  entire  mechanism  of  the 
body. 

Pathology.  The  minute  changes  that 
characterize  tuberculosis  of  bone  in  general 
are  described  in  Chapter  V. 

The  first  indication  of  the  disease  is  usually 
found  in  the  anterior  part  of  a  vertebral  body 
just  beneath  the  fibroperiosteal  layer  of  -the 
anterior  longitudinal  ligament.  From  this 
point  the  granulation  tissue  advances  along 
the  front  of  the  spine  and,  following  the 
course  of  the  bloodvessels,  it  invades  and 
destroys  the  adjacent  vertebral  bodies.  In 
other  instances  the  disease  may  begin  in  the 
interior  of  a  vertebral  body,  most  often  in 
several  minute  foci  near  the  upper  or  lower 
epiphysis.  These  coalescing,  gradually  en- 
large, forming  a  cavity,  surrounded  for  a 
time  by  unbroken  cortical  substance,  which, 
becoming  weaker,  collapses  under  the  pressure  of  the  superin- 
cumbent weight.  Occasionally  the  disease  advances  beneath  the 
anterior  ligament  without  implicating  deeply  the  substance  of  the 
bone — a  form  of  tuberculous  periostitis,  "  spondylitis  superficialis." 
The  intervertebral  disks  appear  to  offer  some  resistance  to  the 
extension  of  the  disease  from  one  vertebra  to  another,  but  when 
the  bone  is  destroyed  on  either  side  they  quickly  disintegrate  and 


Destruction  of  the  bodies 
of  the  first,  second  and  third 
lumbar  vert ebrse— with  the 
resulting  deformity.  (Me- 
nard.) 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


19 


disappear.  The  posterior  part  of  the  spinal  column  usually 
remains  free  from  disease,  with  the  exception  of  the  pedicles  and 
articulations  that  may  be  in  direct  contact  with  the  tuberculous 
process.  In  rare  instances  the  disease  may  begin  in  a  lamina  or 
spinous    process,    or   one   of    the   small   joints  may  be  primarily 


Fig.  2. 


Pott's  disease. 


involved ;  Ijut  such  forms  of  local  tuberculosis  would  hardly  be 
classed  as  Pott's  disease  unless  the  anterior  part  of  the  spine  were 
implicated  also. 

The  course  and  outcome  of  the  disease  depends  upon  its  type. 
In  one  instance  the  area  of  primary  infection  is  small  and  the  local 
resistance   is  sufficient  to  check  its  further  progress,  so  that  cure 


20  OB  TH  OPE  Die  SUBGER  T. 

without  deformity  may  follow.  In  another  the  disease  is  inactive 
and  the  granulation  tissue  undergoes  a  fibroid  transformation  or 
becomes  ossified.  In  such  cases  deformity  may  appear  and 
slowly  increase,  practically  without  symptoms.  In  most  instances, 
however,  the  tuberculous  granulations  advance  more  rapidly, 
destroying  the  bone  or  other  tissue  with  which  they  come  in  con- 
tact; the  usual  retrograde  metamorphosis  to  cheesy  degeneration 
follows,  and  very  frequently  liquefaction  or  abscess  formation. 
This  latter  complication  may  be  dependent  upon  secondary  infec- 
tion, but  the  liability  to  abscess  is  very  much  increased  by  irritation 
or  injury,  and  it  is  decreased  by  absolute  rest  of  the  diseased  part. 

As  a  rule,  in  those  cases  of  moderate  severity  that  come  to 
autoj)sy  during  the  progressive  stage  of  the  disease,  one  finds,  on 
dividing  the  thickened  tissues  in  front  of  the  spine,  a  cavity,  the 
walls  of  which  are  lined  with  tuberculous  granulations  in  various 
stages  of  degeneration,  and  containing  puriform  fluid.  The 
adjoining  vertebral  bodies  present  a  worm-eaten  appearance,  and 
one  or  more  of  them  is  partially  destroyed.  Small  fragments  of 
necrosed  bone  and  "bone  sand"  may  be  present,  together  with 
larger  masses  of  degenerated  tissue,  and  occasionally  sequestra  of 
considerable  size  may  be  found. 

In  other  instances  the  disease  may  begin  in  the  posterior  part 
of  a  vertebral  body,  or  it  may  extend  backward  as  well  as  for- 
ward, and,  forcing  its  way  into  the  vertebral  canal,  it  may  press 
upon  the  spinal  cord  and  involve  its  coverings,  and  thus  cause 
paralysis  of  the  parts  below.  Less  often  pressure  on  the  cord  may 
be  due  to  the  preseuce  of  an  abscess  or  to  a  projecting  fragment 
of  bone.  The  calibre  of  the  spinal  canal  may  be  constricted 
somewhat  by  the  pressure  of  the  superincumbent  weight  upon  the 
softened  and  thickened  tissues  at  the  seat  of  disease;  but,  as  a 
rule,  its  capacity  is  not  directly  lessened  by  the  angular  distortion, 
nor  does  the  degree  of  deformity  directly  influence  the  frequency 
of  paralysis. 

Although  the  disease  may  begin  in  multiple  primary  foci  of 
infection  over  an  extended  area,  or  in  two  or  more  distinct  regions 
of  the  spine  simultaueously,  yet  clinical  observation  seems  to  show 
that  it  is,  in  most  instances,  originally  confined  to  one  or  two 
adjacent  bodies.  From  this  central  point  the  disease  may  extend 
in  either  direction  until  half  the  spine  may  be  implicated ;  but  in 
ordinary  cases  the  final  area  of  deformity  and  rigidity  shows  that 
from  three  to  six  bodies  are  more  or  less  involved  before  cure  is 
established. 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


21 


If  the  disease  is  limited  in  extent,  the  eroded  surfaces  of  the 
adjoining  vertebrae  may  come  into  direct  contact,  but  if  several 
vertebral  bodies  have  been  destroyed  the  upper  portion  of  the 
spine  as  it  sinks  downward  is  often  displaced  backward  so  that 
the  anterior  aspect  of  one  or  more  of  the  upper  segments  may  be 


Fig.  3. 


Fig.  4. 


Destruction  of  the  bodies  of  the  third, 
fourth,  fifth,  sixth,  and  seventh  dorsal  ver- 
tebrae ;  partial  destruction  of  three  others. 
(M6nard.) 


Tlie  deformity  corrected  showing  the  area 
of  the  destructive  process     (Menard.) 


ap])osed  to  the  superior  surface  of  the  first  body  of  the  lower  sec- 
tion (Fig.  3).  Less  often  there  may  be  forward  displacement 
of  the  upper  part  upon  the  lower  (Fig.  1). 

At  all  stages  of  the  disease  resistance  to  its  progress  and  efforts 


22  OR  THOPED IC  S  UR  GER  Y. 

at  repair  are  evident  in  the  affected  parts.  When  this  resistance 
overbalances  the  tendency  to  degeneration,  cure  follows. 

Repair  is  accomplished  occasionally  by  contact  and  solid  union 
of  the  ndjoining  surfaces  of  softened  bone ;  but  usually  the 
anchylosis  is  iu  part  fibrous,  in  part  cartilaginous,  and  in  part 
bony,  and  this  union  may  be  further  strengthened  by  a  callous 
formation  from  the  thickened  tissues  about  the  seat  of  the  disease. 
In  many  instances  the  articular  processes,  the  pedicles  and  laminae, 
become  anchylosed  before  repair  has  advanced  appreciably  in  the 
anterior  portion  of  the  column. 

Cure  may  be  absolute,  as  when  no  vestige  of  the  disease  remains  ; 
it  may  be  practically  assured,  as  when  the  diseased  products 
undergo  calcareous  degeneration  and  are  shut  in  by  a  layer  of  solid 
bone.  In  other  mstances  the  disease  becomes  quiescent  or  but 
slowly  advances,  showing  its  presence  by  exacerbations  of  pain 
or  by  the  formation  of  an  abscess,  long  after  active  symptoms 
have  ceased. 

Etiology.  The  etiology  of  tuberculosis  of  the  spine  does  not 
differ  from  that  of  tuberculosis  of  other  bones ;  the  subject  is  con- 
sidered in  Chapter  V. 

Relative  Frequency.  Tuberculosis  of  the  spinal  column  is  more 
common  than  of  any  other  single  bone  or  joint,  as  might  be 
expected  from  its  greater  area.  This  is  illustrated  by  the  statistics 
of  tuberculous  disease  treated  in  the  out-patient  department  of  the 
Hospital  for  Ruptured  and  Crippled,  New  York,  during  a  period 
of  fifteen  years,  1885-1899: 

Tuberculosis  of  the  spine 3207  cases. 

"  the  hip 2230     " 

"  "  other  joints  inclusive 2408     " 

Also  by  similar  statistics  of  the  Boston  Children's  Hospital, 
for  a  longer  period,  1869-1893  : 

Tuberculosis  of  the  spine 1864  cases. 

"  "    "    hip,  knee,  ankle,  shoulder,  elbow,  and 

wrist  combined 1856      " 

Age.  Pott's  disease,  although  far  more  frequent  in  the  middle 
period  of  childhood,  from  the  third  to  the  tenth  year,  may  occur 
at  any  time  from  earliest  infancy  to  extreme  old  age. 

In  a  series  of  1259  consecutive  cases  of  tuberculosis  of  the 
spine  collected  from  the  records  of  the  out-door  department  of 
the  Hospital  for  Ruptured  and  Crippled,  New  York,  analyzed 
by  Drs.   R.  T.  Frank  and  C.   Gunter,   the  ages  of  the  patients 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  23 

at  the  supposed  time  of  onset  of  the  disease  appeared  to  be  as 

follows  : 

Less  than!  year 38  =  3.1  per  cent. 

Between   1  and  2  years 176  =  14.2 

3     .<      5      "              627  =  50.2  " 

6     "    10      "              234  =  18.3  " 

"        11     "    20      "              89  =  7.2  " 

"        21     "    30      "              43  =  3.5  " 

"         31     "    50      "              31  =  2.6  ^'1 

Over    50     "             11  =  0.8  " 

The  youngest  patient  was  two  months  old,  the  oldest  seventy-one 
years. 

Thorndike/  of  Boston,  from  the  records  of  the  Boston  Chil- 
dren's Hospital  for  thirteen  years,  1883  to  1896,  collected  115 
cases  of  tuberculosis  of  the  spme  in  children  of  two  years  or 
less.  Seven  of  these  were  less  than  six  months,  and  twenty  were 
under  one  year  in  age. 

Howard  Marsh^  has  called  attention  to  Pott's  disease  of 
the  aged,  and  cites  three  cases  in  subjects  of  sixty  or  more  years 

of  age. 

Sex.  Sex  exercises  comparatively  little  influence  on  the  liability 
to  disease  of  this  region.  Of  3797  cases  collected  by  Mohr,  Gib- 
ney,  Fischer,  Taylor,  and  Bradford  and  Lovett,  quoted  by  Hoffa, 
2045  were  in  males  and  1752  were  in  females.  Of  1367  cases 
collected  by  Frank  and  Gunter,  708  (52  per  cent.)  were  m  males 
and  659  (48  per  cent.)  were  in  females;  and  in  2455  cases  tabu- 
lated by  Knight,  1329  were  in  males  and  1126  in  females.  Of 
these  combined  cases  from  the  Hospital  for  Ruptured  and  Crippled, 
3822  in  number,  53.2  per  cent,  were  in  males  and  46.8  per  cent, 
in  females. 

The  Situation  of  the  Disease.  The  dorsolumbar  section  of 
the  spine  is  most  often  affected.  Cervical  disease  is  comparatively 
infrequent. 

In  the  series  of  1355  cases  from  the  records  of  the  Hospital  for 
Ruptured  and  Crippled,  the  attempt  was  made  to  locate  the  origin 
of  the  disease'by  the  most  prominent  spinous  process  m  the  trac- 
ing.    The  following  are  the  conclusions  : 

1  Transactions  American  Orthopedic  AsEOciation,  1896,  vol.  ix. 

2  Ibid.,  1891,  vol.  iv. 


24 


ORTHOPEDIC  SURGERY. 


First  . 

Second 

Third 

Fourtli 

Fifth 

Sixth 

Seventh 

Eighth 

Ninth 

Tenth 

Eleventh 

Twelfth 


No  deformity,  cervical 
"  dorsal 

"  lumbar 


Cervical. 

Dorsal. 

Lumbar. 

Lumbosacral 

3 

26 

94 

13 

3 

43 

96 

15 

42 

64 

20 

46 

57 

18 

49 

6 

22 

76 

24 

82 
97 
92 

110 
71 

120 

854 


Disease  in  two  regions  of  the  spine 


Similar  statistics  are  recorded  by  Julius  Dollinger, '  of  Buda- 
pest, of  700  cases  of  Pott's  disease.  Of  these  the  situation  of 
the  primary  disease  could  be  ascertained  in  538.  Of  this  number. 
in  63  the  disease  was  of  the  cervical,  in  321  of  the  dorsal,  and  in 
154  of  the  lumbar  region. 

The  relative  frequency  of  disease  of  the  different  dorsal  and 
lumbar  vertebrae  was  as  follows  : 


First 

Second 

Third 

Fourth 10 

Fifth 

Sixth 17 

Seventh 33 

Eighth 36 

Ninth 36 

Tenth 43 

Eleventh 38 

Twelfth 64 

321  154 

The  proportionate  length  of  the  different  sections  of  the  spine 
at  the  age  of  five  years  is,  according  to  Professor  Disse  (Skele- 
tlehre,  1896)  : 

Cervical 20.2 

Dorsal 45.6 

Lumbar 34.2 


Dorsal. 

Lumbar 

.      6 

59 

7 

37 

.     12 

31 

.     10 

17 

.     19 

10 

100.0 


If  this   be  contrasted  with  the  percentage  of  the  cases  of  disease 
of   each   section,  it  will  show  that  the  frequency  of  the  disease  in 


'  Die  Behandlung  der  Tuberculosen  Wirbelentziindung.    Stuttgart,  1898. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  25 

the  different  regions  of  the  spine  does  not  correspond  to  the  area, 
as  has  been  suggested,  but  that  it  is  proportionately  much  less  fre- 
quent in  the  cervical  and  much  more  frequent  in  the  dorsal  region. 

Bollinger.  Frank  and  Gunler. 

Cervical     .       .        .    11.7  per  cent.  Cervical    .       .       .7.6  per  cent. 

Dorsal        .        .        .    59.6        "  Dorsal        .        .        .    61.1 

Lumbar     .       .       .    28.6       "  Lumbar     .       .       .    26.2 

This  may  be  explained  apparently  by  the  greater  strain  to  which 
the  middle  and  lower  part  of  the  spine  is  subjected,  as  well  as  by 
the  relative  proportion  of  cancellous  tissue  which  offers  the  oppor- 
tunity for  infection. 

Prognosis.  The  prognosis  in  tuberculous  disease  is  discussed 
in  Chapter  V.  Pott's  disease  is  the  most  dangerous  of  all  the 
tuberculous  affections  of  the  bones  or  joints,  as  would  be  expected 
from  the  relative  importance  of  the  structure  affected  and  of  the 
parts  lying  in  contact  with  it. 

It  is  evident  also  that  the  amount  of  deformity  and  its  situation 
have  a  direct  influence  on  the  prognosis.  In  disease  of  either 
extremity  of  the  spine  the  direct  deformity  is  insignificant  and  the 
secondary  effect  upon  the  trunk  is  slight. 

In  the  typical  ' '  hump-back  "  deformity,  however,  the  contents 
of  the  thorax  and  abdomen  are  necessarily  compressed ;  the  blood- 
vessels are  distorted,  and  the  calibre  of  the  aorta,  which  is  more 
directly  affected,  is  often  much  diminished;  respiration  is  made 
difficult,  and  the  circulation  is  impeded ;  as  a  consequence,  the 
heart  is  usually  hypertrophied  and  valvular  insufficiency  is  not 
infrequent.  Thus  the  vital  functions,  which  are  carried  on  at  a 
disadvantage  even  under  favorable  conditions,  become  impossible 
under  the  added  strain  of  imfavorable  surroundings,  overwork, 
or  disease.  It  is  a  matter  of  common  observation  that  few  of 
those  who  are  markedly  deformed  reach  old  age.  On  the  other 
hand,  it  may  be  assumed  that  slight  deformities,  or  those  which 
do  not  as  directly  interfere  with  the  vital  functions,  exercise  but 
little  influence  upon  the  future  well-being  of  the  patient. 

Although  the  absolute  mortality  of  Pott's  disease  cannot  be 
accurately  estimated,  it  may  be  stated  that  at  least  20  per  cent, 
of  all  patients  die  during  the  progress  of  the  disease  and  within  a 
few  years  after  its  onset,  from  causes  directly  or  indirectly 
dependent  upon  the  local  lesion.  Some  of  these  die  from  general 
dis.semination  of  the  tuberculous  infection  and  tuberculous  menin- 
gitis ;  some  from  exhaustion  following  septic  infection  and  long- 
continued     suppuration,    or    from    amyloid    degeneration    of    the 


26  OB THOPEDIC  SUBGEB  Y. 

internal  organs;  some  from  tuberculosis  of  the  lungs,  and  many 
from  intercurrent  affections  that  are  fatal  because  of  the  devital- 
izing influence  of  the  disease  and  its  complications. 

The  prognosis  of  Pott's  disease  in  the  individual  case  is  influ- 
enced by  many  considerations.  In  one  instance  the  family  history 
is  good,  the  surroundings  are  favorable,  the  patient  is  in  good 
condition,  and  the  disease  is  in  the  early  stage ;  one  is  then  inclined 
to  look  upon  it  as  an  accident,  and  hardly  considers  the  possibility 
of  a  fatal  termination ;  while  in  another  case  the  weakness  and 
undervitalizatiou  of  the  body  are  so  evident  that  the  affection  of 
the  spine  seems  but  an  incident  of  a  general  degeneration. 

Symptoms.  The  most  distinctive  sign  of  Pott's  disease  is 
deformity.  At  an  early  stage  of  the  process  there  may  be  but  a 
slight  irregularity  in  the  contour  of  the  spine,  and  if  several  adja- 
cent vertebral  bodies  are  affected  the  projection  may  be  somewhat 
rounded  in  outline;  but  as  compared  with  other  deformities  of 
the  spine,  that  of  Pott's  disease  is  characteristically  angular,  and 
as  its  cause  is  loss  of  substance,  its  formation  is  accompanied  by 
and  must  have  been  preceded  by  the  symptoms  of  bone  disease. 

Deformity  is  thus  the  evidence  of  a  destructive  process  that 
may  have  existed  for  weeks  or  months  even,  and  only  by  its  early 
recognition  can  the  ideal  result — the  prevention  of  deformity — be 
attained.  The  spine  which,  although  weak,  is  still  straight  may 
be  held  straight ;  but  when  the  deformity  is  present,  it  can  be 
remedied  only  in  part,  and  it  may  be  difficult  even  to  check  its 
further  progress.  For  as  the  upper  segment  of  the  spine  sinks 
forward  and  downward,  the  influences  of  compression  and  attrition 
increase  the  activity  of  the  local  process  and  aggravate  its  effects. 

For  many  years  angular  deformity  was  thought  to  be  the  essen- 
tial sign  of  Pott's  disease,  and  even  now  the  fact  is  not  generally 
recognized  that  the  detection  of  tuberculous  ostitis  of  the  spine  in 
the  early  stage  is  both  possible  and  easy,  if  one  will  apply  the 
same  methods  that  serve  for  the  diagnosis  of  other  affections  not 
attended  by  such  obvious  symptoms  as  external  deformity.  It  is 
to  such  application  of  the  principles  of  differential  diagnosis  that 
attention  is  especially  called. 

The  spine  is  the  chief  support  of  the  body,  possessing  a  free 
mobility  that  accommodates  it  to  every  movement  of  the  trunk 
and  to  every  motion  of  the  limbs  even.  It  is  evident,  therefore, 
that  the  symptoms  of  a  destructive  disease  must  be  pain,  weakness, 
and  impairment  of  normal  motion.  Motion  and  support  are  not, 
however,  the  only  functions  of  the  spine ;  it   contains   the   spinal 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  27 

cord,  from  which  branch  the  nerves  that  supply  the  organs  and 
members  of  the  body.  This  may  be  implicated  at  an  early  stage 
of  the  affection  and  the  sudden  onset  of  paralysis  may  overshadow 
the  symptoms  of  the  original  disease.  In  other  instances  the  tumor 
of  an  abscess — one  of  the  common  accompaniments  of  tuberculous 
disease  of  bone — may  interfere  with  the  functions  of  important 
parts  lying  in  the  neighborhood  of  the  spine,  and  peculiar  symp- 
toms, due  to  this  cause,  may  attract  attention  before  the  primary 
disease  is  suspected.  Such  symptoms  may  be  misleading  and  it 
is  well,  therefore,  to  consider  them  apart  from  those  that  indicate 
the  primary  effect  of  the  disease  upon  the  spine,  considered  as  an 
elastic  support.  These  direct  symptoms  usually  precede  and 
always  accompany  the  secondary  or  complicating  symptoms,  and 
upon  them  the  diagnosis  depends. 

The  primary  and  diagnostic  symptoms  of  Pott's  disease  may  be 
classified  as  follows  : 

(a)  Pain. 

(6)  StifPness. 

(c)  Weakness. 

(d)  Awkwardness. 

(e)  Deformity. 

(a)  Pain.  At  first  thought,  one  might  expect  the  pain  of  Pott's 
disease  to  be  localized  at  the  affected  vertebrae,  and  to  be  accom- 
panied by  sensitiveness  to  pressure  or  even  by  infiltration  and 
swelling  of  the  tissues ;  but  it  will  be  remembered  that  the  bodies 
of  the  vertebrse  are  in  the  interior  of  the  trunk,  practically  speak- 
ing, as  near  to  its  anterior  as  to  its  posterior  surface  (Fig.  9),  and 
that  the  products  of  the  disease  pass  downward  and  forward, 
rarely  backward.  Thus  sensitiveness  to  pressure  on  the  projecting 
spinous  processes  is  unusual,  and  palpation,  except  in  the  cervical 
region,  is  of  comparatively  little  diagnostic  value. 

The  pain  of  Pott's  disease  is  not  localized  in  the  back,  in  the 
neighborhood  of  the  disease,  because  the  filaments  that  supply 
the  bodies  of  the  vertebrae  are  insignificant  parts  of  nerves  that 
are  distributed  to  distant  points — to  the  head,  to  the  limbs,  to  the 
front  and  sides  of  the  trunk — and  to  these  parts  the  pain  is  re- 
ferred; thus  "earache"  or  "stomach-ache"  or  "  sciatica "  may 
be  symptomatic  of  Pott's  disease.  The  pain  of  Pott's  disease  is 
by  no  means  constant;  it  is  induced  by  jars  or  by  sudden  or 
unguarded  movements.  It  is  often  worse  at  night,  when,  after 
the  relaxation  of  tlie  muscular  spasm  that  has  protected  the  part, 
the  unconscious  movements  during  sleep  cause  discomfort  or  pain, 


28 


ORTHOPEDIC  SURGERY. 


Fig.  5. 


aud  the  child  moans  in  its  sleep,  or  is  restless,  and  sometimes  it 
wakes  with  a  cry — "night  cry." 

(6)  Impairment  of  Function  or  Loss  of  Normal  Mobility  :  Stiffness. 
Stiifness  of  the  spine  is  in  part  volnntary,  in  the  sense  that  the 
patient  adapts  his  movements  and  attitndes  to  the  disease  and  pain 
— in  order  to  avoid  as  far  as  possible  strain  aud  jar — but  the 
essential  and  characteristic  stiffness  of  Pott's  disease  is  caused 
by  the  involuntary  muscular  tension  and  contraction  of  the  muscles 
about  the  seat  of  disease.  This  reflex  muscular  spasm  varies  in 
degree,  according  to  the  state  of  the  underlying  disease.  It  may 
fix  the  spine  or  it  may  be  evident  only  at  the  extremes  of  motion, 
but  it  is  always  present,  preceding  deformity  and  accompanying 
it  until  cure  is  established ;  thus  it  is  the 
most  important  of  the  diagnostic  symptoms 
of  Pott's  disease. 

(c)  Weakness.  As  the  disease  affects  the 
most  important  support  of  the  body,  it  is 
a  direct  as  well  as  an  indirect  cause  of  weak- 
ness, and  the  more  vulnerable  the  spine, 
the  more  pronounced  is  this  symptom ;  thus 
in  a  young  cliild,  whose  spine  is  in  great 
part  cartilaginous,  evidence  of  weakness  is 
shown  by  the  "  loss  of  walk,"  the  refusal  to 
stand,  and  by  the  instinctive  desire  for 
support,  at  an  early  stage  of  the  disease. 

(d)  Change  in  Attitude  :  "Awkwardness," 
This  really  sums  up  the  effects  of  the  pre- 
ceding symptoms,  since  it  is  evident  that 
pain,  weakness,  and  rigidity  must  cause  a 
change  in  the  appearance  and  in  the  habit- 
ual attitudes  of  the  patient.  Such  symp- 
tomatic attitudes  may  be  almost  diagnostic 
of  the  disease  and  of  the  part  of  the  spine 
involved. 

{e)  Change  in  the  Contour  of  the  Spine  : 
Deformity.  The  deformities  of  Pott's  dis- 
ease may  be  classified  as  follows  : 

1.  Bone  deformity. 

2.  Muscular  deformity. 

3.  Compensatory  deformity. 

The  characteristic  angular  projection  due  to  destruction  of  bone 
has  been  described  already. 


A,  direct  defiirraily  ;  B,  com- 
pensatory deformity.  The 
dotted  line  indicates  the  nor- 
mal contour  of  the  spine. 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


29 


Muscular  deformity  is  the  distortion  due  to  muscular  spasm  or 
contraction.  Of  this,  the  wry  neck,  symptomatic  of  cervical  dis- 
ease, and  psoas  contraction  in  the  lower  region  of  the  spine,  are 
the  most  familiar  examples. 

Compensatory  deformity  signifies  the  more  general  effect  of  the 
local  disease  and  local  distortion  upon  the  spine  as  a  whole  (Fig.  5). 
Thus  an  angular  projection  must  be  balanced  by  a  compensatory 
incurvation,  and  lateral  distortion  in  one  direction  by  lateral  dis- 
tortion in  another. 

These  three  deformities  are,  of  course,  nearly  related,  and  they 
are  usually  combined,  although  muscular  distortion  may  precede 

Fiu.  6. 


Normal  contour  and  flexibility  ot  the  spine. 


the  stage  of  bone  destruction,  while  the  compensatory  changes  are 
not  immediately  apparent.  On  the  other  hand,  the  secondary 
changes  in  the  contour  of  the  spine  may  catch  the  eye  before  the 
primary  local  deformity  is  detected. 

Lateral  deviation  of  the  spine  is  not  infrequent;  it  may  be  a 
direct  distortion  at  the  seat  of  the  disease,  caused  by  the  destruc- 
tion of  the  side  of  a  vertebral  body  (Fig.  22),  but  more  often  it  is 
a  secondary  effect  of  such  irregular  erosion  at  one  or  the  other 
extremity  of  the  spine,  or  the  effect  of  muscular  contraction,  or 
it  may  be  due  to  simple  weakness,  in  which  case  it  is  a  transient 
symptom. 

Finally,  even  at  the  earliest  stage  of  the  disease,  there  is  almost 
always  a  slight  change  in  the  outline  of  the  spine  due  to   local 


30 


ORTHOPEDIC  SURGERY. 


rigidity;  the  spine  no  longer  forms  a  long,  regular  curve  when  the 
body  is  bent  forward,  but  as  one  section  remains  more  or  less 
rigid  while  the  other  bends,  the  outline  is  broken  at  or  near  the 
seat  of  the  disease  (Fig.  7). 

Secondary  or  Complicating  Symptoms,  (a)  Abscess.  This 
may,  by  its  size  or  situation,  cause  peculiar  symptoms.  In  the 
retropharyngeal  space  it  may  interfere  with  respiration  and 
deglutition.      In  the   thoracic   region   it   might   be   mistaken   for 


Fig.  7. 


Incipient  Pott's  disease.    Showing  the  breaij  in  the  contour  of  the  spine,  of  which  the 
normal  flexibility  is  but  slightly  impaired. 


pleurisy  or  empyema,  and  when  it  forms  a  tumor  in  the  iliac  fossa 
it  may  interfere  with  locomotion. 

(b)  Paralysis.  This  is  usually  a  late  symptom,  but  if  the  disease 
begins  in  the  centre  or  posterior  part  of  a  vertebral  body  it  may 
implicate  the  spinal  cord  before  deformity  is  apparent. 

Abscess  and  paralysis  are  symptoms  that  may  be  explained  by 
Pott's  disease,  but  other  than  by  calling  attention  to  disease  of  the 
spine  as  a  possible  cause  of  the  complication,  they  do  not  aid  one 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  31 

in  determining  the  diagnosis ;  for  this  reason  they  are  classed  as 
secondary  symptoms. 

General  Symptoms.  Especial  stress  is  laid  by  certain  writers 
upon  the  diagnostic  value  of  a  slight  but  constant  elevation  of  the 
temperature.  This  is  usually  present  if  the  disease  is  active  or 
when  an  abscess  is  approaching  the  surface,  but  the  positive  value 
of  the  symptom  in  early  or  quiescent  cases  is  doubtful.  One  may 
expect  also  that  a  patient  suffering  from  tuberculous  disease  of  the 
spine  will  present  some  evidence  of  a  painful  and  depressing 
affection,  or  some  evidence  of  inherited  or  acquired  weakness ;  yet 
it  must  be  remembered  that  the  absence  of  such  general  symptoms 
would  not  exclude  Pott's  disease. 

The  Contour  and  Flexibility  of  the  Normal  Spine.  In  the  enum- 
eration of  the  early  symptoms  of  Pott's  disease,  two  have  been 
noted  as  of  especial  importance — the  impairment  of  normal 
mobility  and  the  effect  of  the  disease  upon  the  contour  of  the  spine 
and  upon  the  attitudes  of  the  patient.  Therefore,  in  the  study  of 
the  normal  spine  the  standard  with  which  that  suspected  of  disease 
must  be  compared — mobility  and  contour — at  different  ages  and 
under  different  conditions  should  receive  especial  consideration. 

The  spine  as  a  whole  is  a  flexible  column,  yet  it  has  a  fixed 
contour;  it  curves  forward  in  the  upper,  backward  in  the  middle, 
and  forward  again  in  the  lower  region.  These  curves  are  essen- 
tially the  effect  of  the  force  of  gravity  and  of  the  action  of  the 
muscles  in  balancing  the  weight  of  the  body  in  the  upright  atti- 
tude. In  the  adult  they  are  practically  constant ;  in  early  child- 
hood they  can  be  nearly  obliterated  by  traction  in  the  horizontal 
position ;  and  in  infancy  they  do  not  exist.  If  the  newborn  infant 
be  placed  in  the  sitting  posture,  the  head  falls  forward  and  the 
spine  bends  in  one  long,  backward  curve,  characteristic  of  weak- 
ness. If  it  be  placed  on  the  back  and  the  legs  be  drawna  down 
from  their  habitual  attitude  of  semiflexion,  it  will  be  noticed 
that  the  range  of  extension  is  somewhat  limited  because  of  the  ab- 
sence of  the  lumbar  curve  and  the  inclination  of  the  pelvis.  When 
the  gain  in  muscular  power  is  sufficient  to  enable  the  infant  to 
raise  and  control  the  head,  the  curve  of  the  neck  appears.  Later 
when  the  child  stands,  the  erector  spinse  muscles  hold  the  body 
upright  against  the  resistance  of  the  iliopsoas  group  and  of  the 
ligaments  of  the  hip-joint;  thus  the  lumbar  curve  and  the  inclina- 
tion of  the  pelvis  result  and  the  normal  contour  of  the  spine  is 
established. 

If  from  the  odontoid  process  of  the  axis  of  a  normal  individual 


32 


OB  THOPEDIC  8  UB  GEB  Y. 


Fig.  8. 


in  the  erect  posture  a  line  be  dropped  to  the  ground,  this  perpen- 
dicular or  weight  line,  about  which  the  weight  of  the  body  is 
balanced,  will  indicate  the  curve  of  the  spine,  and  divide  it  into 
sections  that  correspond  sufficiently  well  to  function.     The  cervical 

curve  ends  at  the  second  dorsal,  the 
thoracic  curve  at  the  twelfth  dorsal,  and 
the  lumbar  curve  at  the  sacrovertebral 
angle  (Fig.  8). 

What  has  been  spoken  of  as  the 
normal  contour  of  the  spine  varies  con- 
siderably in  the  adult.  It  is  affected 
by  the  occupation  and  many  other  cir- 
cumstances ;  of  this,  the  round  shoulders 
of  the  cobbler  or  the  weaver,  the  stoop 
of  weakness,  of  old  age  and  the  like,  are 
familiar  examples;  but  in  childhood  dis- 
tinct variations  from  the  normal  contour 
almost  always  have  a  clearly  defined 
pathological  cause.  As  the  normal  con- 
tour is  the  effect  of  the  balancing  of  the 
body  in  the  upright  posture,  it  is  evi- 
dent that  if  the  outline  of  one  part  is  per- 
manently changed,  compensation  for  this 
change  must  be  made  in  another  part. 
Thus  when  deformity  is  well  marked, 
the  normal  curves  of  the  spine  are  often 
completely  reversed  (Fig.  5),  and  even  at  an  early  stage  of  the 
disease  the  abnormal  contour  will  often  attract  attention,  long 
before  the  characteristic  angular  projection  has  become  apparent. 


The  divisions  of  the  spine. 


Divisions  of  the  Spine. 

Although  the  spine  is  a  flexible  column  whose  outline  changes 
with  every  movement  and  posture,  yet  the  range  and  char- 
acter of  this  motion  vary  greatly  in  different  parts.  In  the  cer- 
vical and  lumbar  regions  motion  is  extensive,  because  of  the 
relatively  large  proportion  of  elastic  intervertebral  substance, 
because  of  the  direction  of  the  articular  surfaces,  and  because 
the  centre  of  motion  is  near  the  middle  of  the  body.  Motion  is 
very  limited  in  the  thoracic  region,  because  the  intervertebral 
disks  are  thin,  because  of  the  overlapping  spinous  processes,  and 
because  it  forms  a  part  of  the  rigid  thorax.  Where  free  motion 
is   essential   to   the  habitual  attitudes,   interference  with  normal 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


33 


motion   and   the   other   attendant    symptoms   of  disease    will   be 
apparent  earliest.      Thus  one  more  often  has  the  opportunity  for 


Fig.  9. 


5!. 


'^■^, 


Aortcu 


phrer^ 


<ry 


Cross-section  of  the  body  of  a  child  at  the  third  dorsal  vertebra.    (Dwight.) 

eirly  diagnosis    in   disease  of   the   lumbar   and   cervical   regions, 
because  in  the  one  the  motions  necessary  in  stooping,  sitting  and 

3 


34  OR THOPEDIC  SURGEB  Y. 

standing  are  constrained,  and  in  the  other  the  neck  is  stiff,  or  the 
head  is  turned,  or  drawn  from  the  normal  line.  In  the  thoracic 
region  early  diagnosis  is  less  often  made,  because  in  this  section 
motion  is  so  unimportant  that  its  restraint  may  escape  the  atten- 
tion of  the  patient  or  parent.  In  considering  diagnosis,  therefore, 
and,  in  fact,  treatment  and  prognosis,  one  should  divide  the  spine 
mto  three  sections  to  correspond  with  function  : 

1.  The  neck  part,  that  allows  free  motion  of  the  head,  ending 
at  the  third  dorsal  vertebra. 

2.  The  rigid  thoracic  part,  which  includes  the  third  and  the 
tenth  dorsal  vertebrse. 

3.  The  lower  part,  made  up  of  the  two  lower  dorsal  and  the 
lumbar  vertebrae,  in  which  the  principal  movements  of  the  trunk 
are  carried  out  (Fig.  8). 

One  must  bear  in  mind  the  distribution  of  the  nerves,  because 
the  characteristic  pain  is  referred  to  their  terminations,  also  the 
parts  in  relation  to  the  spine  at  different  levels  that  may  be  impli- 
cated in  the  disease.  Thus,  remembering  that  the  symptoms 
of  Pott's  disease  are  in  general,  stiffness,  weakness,  pain  and 
deformity,  one  will  always  apply  these  symptoms  to  a  particular 
region  of  the  spine,  and  will  picture  to  himself  the  effect  of  such 
stiffness,  weakness,  and  deformity  at  this  or  that  vertebra ;  the 
effect  of  an  abscess  ui  this  or  that  situation,  and  the  area  of  paral- 
ysis that  might  be  caused  by  pressure  on  the  cord  at  one  or  another 
level. 

Landmarks.     The  atlas  is  on  a  line  with  the  hard  palate. 

The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth. 

The  transverse  process  of  the  atlas  is  just  below  and  in  front  of 
the  tip  of  the  mastoid  process. 

The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  vertebra. 

The  upper  margin  of  the  sternum  is  opposite  the  disk  between 
the  second  and  third  dorsal  vertebrae. 

The  junction  of  the  first  and  second  sections  of  the  sternum  is 
opposite  the  fourth  dorsal  vertebra. 

The  tip  of  the  ensiform  cartilage  is  opposite  the  lower  part  of 
the  body  of  the  tenth  dorsal  vertebra. 

The  anterior  extremity  of  the  first  rib  is  on  a  line  with  the  fourth 
rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  with  the  ninth, 
the  seventh  with  the  eleventh. 

The  scapula  overlaps  the  second  and  the  seventh  ribs,  its  lower 
angle  being  opposite  the  centre  of  the  eighth  dorsal  vertebra. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  35 

The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and 
the  interval  between  the  second  and  third  dorsal  spines  are  in  the 
same  plane. 

The  most  constant  landmark  from  which  to  count  is  the  spinous 
process  of  the  fourth  lumbar  vertebra,  which  is  on  a  line  with  the 
highest  point  of  the  crest  of  the  ilium.  The  umbilicus  is  near  the 
same  plane. 

The  Inclination  of  the  Pelvis.  In  the  erect  attitude  the  plane  of 
the  brim  forms  an  angle  of  60°  to  65°  with  the  horizon. 

The  tip  of  the  coccyx  is  opposite  the  lower  border  of  the  sym- 
physis pubis. 

Length  of  the  Spinal  Cord.  In  the  adult  the  spinal  cord  termi- 
nates at  the  lower  margin  of  the  first  lumbar  vertebra.  At  birth 
it  extends  to  the  third  lumbar  vertebra  and  its  membranes  to  the 
second  division  of  the  sacrum. 

The  Intervertebral  Disks.  In  the  adult  the  intervertebral  disks 
form  41.9  per  cent,  of  the  cervical,  26.4  per  cent,  of  the  dorsal, 
and  44. 6  per  cent,  of  the  lumbar  regions  of  the  spine  (Dwight). 

The  character  of  the  disease,  its  manifestations,  and  its  effects 
upon  the  spine  having  been  outlined,  the  student  is  now  brought, 
as  it  were,  into  actual  contact  with  the  patient  and  his  friends. 
And  as  Pott's  disease  is  the  most  important  of  the  chronic  affec- 
tions of  childliood,  it  will  serve  as  a  type  to  illustrate  methods  of 
examination  and  of  treatment  as  applied  in  orthopedic  practice. 

The  Rational  Signs.  The  symptoms  of  Pott's  disease  vary 
decidedly,  not  only  with  the  region  of  the  spine  involved,  but  also 
with  the  age  and  surroundings  of  the  patient.  Like  other  forms 
of  tuberculous  disease  it  is  an  insidious  chronic  affection,  and  its 
early  symptoms  may  fail  to  attract  attention,  because  they  are 
irregular  or  intermittent.  The  child  may  cry  after  overexertion 
or  injury,  but  otherwise  it  may  appear  to  be  perfectly  well  for 
weeks  or  months  even.  When  the  diagnosis  is  evident,  however, 
the  mother  almost  always  recalls  the  fact  that  something  was 
"  wrong,"  that  it  was  fretful  and  disinclined  to  play,  that  it  liked 
to  lie  on  the  floor,  that  it  was  awkward  in  its  movements,  that  it 
was  troubled  by  a  cough  or  indigestion,  or  by  oppression  of  breath- 
ing. One,  or  many,  of  such  symptoms  may  have  existed  for 
months ;  but,  as  a  rule,  it  is  not  until  deformity  appears  that  the 
child  is  brought  for  treatment.  It  is  often  after  a  fall  or  violent 
play  that  the  evidence  of  pain  or  weakness  can  no  longer  be  over- 
looked, so  that  injury  is  likely  to  occupy  a  prominent  place  in  the 
history. 


36  OR THOPEDIC  S UB GEB  Y. 

History.  The  history  of  the  disease  as  obtained  from  the  parent 
is  usually  indefinite  and  misleading.  Certain  points,  however,  of 
relative  importance  may  be  ascertained  by  an  examination  some- 
what as  follows  : 

One  asks  if  the  immediate  relatives  of  the  child  have  suffered 
from  phthisis  or  other  form  of  tuberculosis,  as  this  mi^ht  indicate 
a  predisposition  to  disease,  and  thus  affect  the  prognosis. 

One  asks  if  the  child  has  been  robust  or  the  reverse,  and  if 
recovery  from  the  ordinary  ailments  of  childhood  was  prompt 
or  tedious,  in  order  that  one  may  judge  of  the  quality  of  the 
patient. 

One  next  asks,  not  "  how  long  has  the  child  been  ill?"  for  this 
is  usually  understood  to  refer  to  the  duration  of  the  more  decided 
symptoms ;  but  "  when  was  the  child  last  perfectly  well  ?"  One 
asks  particidarly  as  to  the  onset  of  the  first  symptoms,  whether  it 
was  sharp  and  decided,  or  gradual  and  ill-defined;  if  the  symp- 
toms were  preceded  by  contagious  disease.  This  latter  is  an 
important  question,  because  measles,  for  example,  predisposes  to 
tuberculous  infection,  or  at  least  to  its  local  outbreak,  and  diph- 
theria is  often  followed  by  paralysis  or  by  weakness  that  may 
simulate  certain  symptoms  of  Pott's  disease.  The  character  of 
the  injury  that  almost  every  pati-ent  is  supposed  to  have  received 
is  then  investigated.  It  should  be  made  clear  whether  the  injury 
was  the  direct  cause  of  the  symptoms,  or  if  it  may  have  simply 
aggravated  or  brought  to  light  the  dormant  disease,  or  if,  as  is 
often  the  case,  there  is  simply  an  indefinite  remembrance  of  an 
injury  which  has  no  connection  with  the  symptoms. 

To  establish  injury  as  the  sole  and  direct  cause  of  symptoms, 
the  patient  must  have  been  well  at  the  time  of  the  accident,  the 
symptoms  must  have  followed  immediately  and  must  have  persisted 
since ;  and,  finally,  the  symptoms  must  be  of  a  nature  to  be  ex- 
plained by  a  definite  injury. 

By  careful  questioning  one  may  usually  determine  whether  the 
symptoms  of  which  the  patient  complains  are  acute  or  chronic. 
This  is  of  importance,  because  tuberculosis  is  a  chronic  disease — one 
of  the  few  chronic  diseases  of  childhood — although  its  exacerba- 
tions may  resemble  the  symptoms  of  acute  disease  or  even  injury. 

However  important  a  correct  history  may  be,  it  is  upon  the 
physical  examination  that  the  diagnosis  practically  depends. 

Physical  Signs.  The  physical  examination  begins  on  the  first 
sight  of  the  patient,  for  one  may  note  then  the  general  condition 
and  the  actions  and  postures;  but  the  ultimate  purpose  of  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  37 

examiner  is  to  compare  the  appearance  and  tiie  mobility  o£  the 
spine  suspected  of  disease  with  the  normal  standard. 

Voluntary  actions  and  attitudes  are  important,  because  they 
show  the  adaptation  of  the  body  to  the  disease,  the  conscious  and 
unconscious  efforts  of  the  patient  to  guard  the  weak  part  from 
strain  and  from  motions  that  cause  discomfort  and  pain.  Inspec- 
tion, palpation,  and  the  tests  of  voluntary  and  passive  motion  are 
of  still  greater  importance,  because  by  such  means  one  may  demon- 
strate the  presence  of  disease  and  localize  it  with  accuracy. 

The  examination  must  be  purposeful.  When  one  asks  the 
patient  to  pick  up  a  coin  from  the  floor,  it  is  to  test  the  lower 
region  of  the  spine  for  the  symptoms  of  weakness  and  stiffness. 
The  ability  to  perform  the  act  with  ease  by  no  means  excludes 
disease  of  the  spine  in  the  regions  not  especially  involved  in  the 
movements  of  stooping  or  turning  the  body,  although  this  would 
appear  to  be  the  general  belief. 

Such  tests  must  not  only  be  purposeful,  but  they  must  be 
adapted  to  the  age  and  intelligence  of  the  patient.  The  child  that 
refuses  to  pick  up  a  coin  will  often  gather  up  its  clothing,  because 
it  wishes  to  be  dressed  again.  If  it  will  not  stoop,  it  will  rise 
usually  if  placed  in  the  recumbent  or  sitting  posture — an  equally 
useful  test.  A  child  will  walk  toward  its  mother  if  placed  at  a 
distance  from  her.  It  will  always  turn  its  head  toward  her ;  thus 
voluntary  motion  of  the  cervical  region  may  be  tested  by  changing 
the  mother's  position,  while  the  child  is  held  by  the  examiner. 
Young  children  that  struggle  and  resist  passive  motion  if  placed 
on  the  table,  submit  quietly  when  held  in  the  mother's  arms. 

Various  simple  and  effective  tests  will  suggest  themselves  to 
the  examiner  who  has  a  definite  purpose  in  view,  but  much  patience 
may  be  required  in  early  cases,  and  several  examinations  may  be 
necessary  before  the  presence  or  absence  of  disease  can  be  definitely 
determined.  It  is  important  to  remember  that,  in  childhood  at 
least,  abnormal  symptoms  always  have  a  cause ;  therefore,  a  patient 
should  be  kept  under  observation  until  the  cause  is  discovered. 

Of  all  the  early  signs  of  Pott's  disease  muscular  rigidity  or  reflex 
muscular  spasm  is  the  most  important,  since  it  precedes  deformity 
and  accompanies  it  until  cure  is  finally  established.  It  is  a  spasm 
that  resists  motion  in  all  directions ;  thus  it  may  be  distinguished 
from  the  spasm  or  contraction  of  certain  groups  of  muscles  caused 
by  irritation  or  inflammation  not  connected  with  the  spine.  For 
in  such  instances  motion  is  limited  only  in  the  directions  directly 
opposed  by  the  muscular  contraction.     True  reflex  muscular  spasm 


38  OBTROPEDIG  SURGERY. 

is  quite  indepeadeut  of  the  will,  and  thus  it  may  be  distinguished 
from  simple  voluntaiy  resistance  on  the  part  of  the  patient. 

The  muscular  rigidity  is  most  marked  in  the  neighborhood  of 
the  disease,  but  it  extends  to  a  greater  or  less  distance  according  to 
the  acuteness  of  the  local  process  and  the  susceptibility  of  the  patient. 

Even  at  an  early  stage  the  situation  of  the  disease  is  usually 
shown  by  a  slight  irregularity  of  the  spine  in  the  centre  of  the 
area  made  rigid  by  muscular  spasm,  as  well  as  by  the  change  of 
contour.  This  change  in  outline  and  in  flexibility  may  be  demon- 
strated by  bending  the  patient  forward.  If  the  spine  forms  a  long, 
even,  regular  curve,  and  if  there  is  no  evidence  of  pain  or  rigidity 
when  such  an  attitude  is  assumed.  Pott's  disease  is  extremely 
improbable.  If,  on  the  other  hand,  the  outline  of  the  curve  is 
broken ;  if  the  motion  of  one  section  of  the  spine  is  restrained  by 
muscular  rigidity,  disease  may  be  suspected  ;  and  if  other  evidence 
of  tuberculous  ostitis  is  present,  the  diagnosis  may  be  made  with 
certainty  (Figs.  6  and  7). 

By  a  careful  physical  examination  one  may  expect  to  detect 
Pott's  disease  at  its  inception  and  to  fix  upon  its  location,  or  at 
least  upon  the  point  suspected  of  disease.  One  will  then  ask 
one's  self  if  tuberculous  disease  of  the  bodies  of  the  vertebrae  of  this 
particular  region  will  satisfactorily  explain  all  the  symptoms  of 
which  the  patient  complains ;  if,  for  example,  the  pain  corresponds 
to  the  distribution  of  the  nerves  ;  if  restraint  of  function  will 
explain  the  attitudes  of  the  patient,  and  if  the  change  in  contour 
is  significant  of  a  destructive  process. 

As  has  been  stated,  the  symptoms  and  the  effects  of  the  disease 
differ  according  to  the  function  of  the  part  of  the  spine  involved ; 
the  further  examination  should  be  conducted,  therefore,  from 
this  standpoint. 

The  Regional  Examination. 

1.  The  Lower  Region.  Considering  the  regions  of  the  spine 
in  the  order  of  liability  to  disease,  one  begins  with  the  lower  sec- 
tion, comprising  the  lumbar  and  the  two  lower  dorsal  vertebrae, 
that  more  nearly  correspond  in  shape  and  function  to  the  lumbar 
than  to  the  thoracic  division. 

This  is  the  region  of  constant  and  extensive  motion ;  thus  the 
painful  rigidity,  characteristic  of  the  disease,  is  often  marked 
long  before  the  stage  of  bone  destruction. 

The  characteristic  attitude  of  the  patient  is  one  of  what  might 
be  called  overerectness,   and   in  many  instances  there  is  an  in- 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


39 


creased  hollovmess  (lordosis)  of  the  back  (Figs.  10  and  12);  thus 
the  prominent  abdomen  may  first  attract  attention.  The  walk  is 
careful,  and  a  peculiar  tip-toeing  step,  the  feet  being  slightly 
inverted  to  avoid  the  jar  of  striking  the  heels,  is  often  observed; 
this  is,  however,  not  a  peculiarity  of  disease  of  this  region  alone, 
but  is  rather  an  evidence  that  the  spine  is  sensitive  to  slight  jars. 
More  characteristic  of  lumbar  disease  is  a  peculiar  swagger  or 


Fm.  10. 


Fig.  11. 


Disease  of  the  upper  lumbar  region  before 
the  stage  of  deformity,  showing  abnormal 
lordosis. 


The  same  patient  (Fig.  10)  five  years 
later,  showing  deformity. 


waddle,  explained  in  part  by  the  exaggerated  lordosis,  and  in 
part  by  the  loss  of  the  accommodative,  balancing  motion  of  the 
lumbar  spine,  as  the  weight  falls  alternately  on  each  limb  in 
walking. 

The  increased  lumbar  lordosis,  so  characteristic  of  the  early 
stage  of  the  disease,  is  capable  of  several  explanations.  It  is 
partly  voluntary ;  as  bending  the  body  forward  brings  pressure 


40  ORTHOPEDIC  SUBOERY. 

upon  the  diseased  vertebral  body,  so  bending  it  backward  relieves 
this  pressure.  It  is  partly  involuntary,  caused  by  the  contrac- 
tion of  the  large  muscular  masses  on  the  posterior  aspect  of  the 
spine ;  and  it  is  in  part  compensatory,  as  the  slight  psoas  con- 
traction which  is  often  present  has  a  tendency  to  tilt  the  pelvis 
forward,  necessitating  a  greater  compensatory  backward  inclina- 
tion of  the  body. 

As  the  disease  progresses  the  lumbar  section  becomes  straighter, 
and  finally  it  may  project  backward  in  the  characteristic  angular 
deformity.  Yet  even  after  the  lordosis  lias  been  obliterated  the 
backward  inclination  of  the  body  still  continues  as  a  compensation 
for  the  change  in  balance,  which  the  transformation  of  the  for- 
ward curve  to  a  posterior  deformity  has  necessitated  (Fig.  11). 
Thus  overerectness  or  backward  inclination  of  the  body  charac- 
terizes the  disease  of  this  region  from  its  beginning  to  its  end  in 
uncomplicated  cases. 

Slight  psoas  contraction  as  a  part  of  the  general  muscular  spasm 
about  the  diseased  area  simply  increases  the  lordosis ;  but  if  the 
contraction  is  greater,  when  for  example  an  abscess  is  present 
which  involves  the  substance  of  the  psoas  muscles  or  forms  a 
painful  tumor  in  the  pelvis,  the  erect  attitude  is  no  longer  possible. 
The  thighs  are  drawn  toward  the  body,  and  the  body  is  inclined 
forward  to  relax  the  tension.  As  this  greater  contraction,  with  the 
abscess  that  is  usually  its  cause,  is  commonly  unilateral  the  patient 
"  favors "  the  flexed  limb,  and  the  resulting  limp  is  often  mis- 
taken for  a  sign  of  hip  disease.  Unilateral  psoas  contraction  is, 
in  fact,  so  often  present  when  the  patient  is  first  brought  for  treat- 
ment, that  a  limp  and  the  accompanymg  inclination  of  the  body 
may  be  considered  as  characteristic  of  disease  of  the  lumbar  region 
at  a  someAvhat  advanced  stage  (Fig.  13), 

The  location  of  the  j^ain  depends  upon  the  distribution  of  the 
nerves  that  supply  the  diseased  vertebrae  or  that  pass  in  their 
vicinity ;  it  may  radiate  over  the  inguinal  region  or  backward  to 
the  loins  or  buttocks  or  doAAoi  the  front  or  back  of  the  thighs  to 
the  knees.  Painful  "  cramj)  "  is  sometimes  a  prominent  symp- 
tom ;  the  limb  is  spasmodically  drawn  toward  the  body  and  the 
patient,  seizing  it  with  both  hands,  shrieks  with  pain. 

Lateral  inclination  of  the  body  is  often  present.  It  is  usually  a 
symptom  of  unilateral  psoas  contraction  and  abscess ;  it  may  be 
due  also  to  unilateral  contraction  of  the  muscles  of  the  back,  or 
at  a  later  stage  it  may  indicate  collapse  or  destruction  of  one  side 
of  a  vertebral  body.      In  other  instances  it  is  not  a  fixed  attitude, 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


41 


but  is  simply  a  voluntary  adaptation  to  weakness  or  pain  ;  thus 
one  may  find  a  large  abscess  in  one  pelvic  fossa  unaccompanied 
by  psoas  contraction,  while  the  body  is  inclined  toward  the 
opposite  side,  apparently  because  the  weight  is  supported  habitu- 
ally on  this  limb. 


Fig.  12. 


Fig.  13. 


Disease  of  the  lumbar  region.    First 
symptom,  pain  in  the  Isnees. 


Disease  of  lumbar  region  with  right  iliopsoas 
abscess  and  psoas  contraction. 


The  stiffness,  loeakness,  and  pain,  characteristic  of  disease  in 
this  region  are  exemplified  in  many  ways;  for  example,  the  child 
may  be  unable  to  turn  in  bed;  it  is  slow  and  awkward  in  rising 
in  the  morning  or  in  changing  from  an  attitude  of  rest  to  one  of 
activity.'  It  often  prefers  to  stand  rather  than  to  sit,  because  in 
the  latter  position   more   weight  is   thrown   upon   the   sensitive 


42 


OR  T HOPE  Die  S  UB  GEB  Y. 


vertebral  bodies.  When  seated,  particularly  when  riding  in  a 
carriage  or  street  car,  the  patient  often  sits  upon  the  edge  of  the 
seat,  the  shoulders  only  touching  the  back,  while  the  hands  rest 
instinctively  on  the  seat,  partially  supporting  the  weight  and 
steadying  the  spine. 

Stooping,  a  posture  that  increases  the  pressure  on  the  diseased 
vertebral  bodies  and  which    necessitates  muscular  tension  and 

strain  in  regaining  the  erect  posi- 
tion, is  particularly  difficult  and 
it  is  always  avoided  by  the 
patient  if  the  disease  is  at  all 
acute.  For  example,  when  the 
child  is  asked  to  pick  up  an  ob- 
ject from  the  floor,  it  either  re- 
fuses or  it  squats  on  the  heels 
or  drops  upon  the  knees  (Fig.  14) 
instead  of  flexing  the  spine  as  in 
health.  Young  children,  having 
seized  the  object  on  the  floor,  re- 
gain the  erect  attitude  by  push- 
ing the  body  up  by  the  pressure 
of  the  hands  on  the  thighs.  If 
the  child  is  placed  upon  the  floor 
it  will,  if  possible,  seize  the  moth- 
er's dress  or  will  crawl  to  a  chair 
or  other  object  upon  which  the 
body  may  be  drawn  up  by  the 
arms,  so  that  the  discomfort 
caused  by  muscular  contraction  of  the  back  muscles  may  be 
avoided. 

After  the  inspection  and  the  observation  of  the  motions  and 
attitudes  of  the  patient,  the  examination  of  the  range  of  passive 
motion  is  made.  The  patient  is  placed  at  full  length  face  downward 
on  a  table,  and  the  range  of  extension  and  of  lateral  motion  is 
tested  by  lifting  the  legs  and  swaying  the  body  gently  from  side 
to  side  (Fig.  15).  The  spine  is  so  flexible  in  childhood  that 
rigidity  even  in  the  upper  dorsal  region  may  be  demonstrated  by 
this  method,  and  in  testing  the  lumbar  region  the  thorax  should 
be  fixed  by  the  hand  of  the  examiner.  While  the  patient  remains 
in  this  attitude,  one  should  test  for  psoas  contraction.  The 
pelvis  is  pressed  firmly  against  the  table  with  one  hand,  while 
the  leg,  held  in  the  line  of  the  body,  is  gently  lifted  by  the  other 


Lumbar  disease.    The  mauuer  of  picking 
up  an  object. 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


43 


(Fig.  16).  As  tested  in  this  manner,  the  normal  range  of  hyper- 
extension  at  the  hip-joint  should  allow  the  knee  to  be  lifted  two 
or  three  inches  from  the  table.     Slight  restriction  of  extension 


Fig.  15. 


Showing  the  rigidity  of  the  spine  before  appearance  of  deformity. 
Fig.  Ifi. 


Test  for  psoas  contraction. 


of  both  thighs,  indicating  a  slight  degree  of  psoas  contraction, 
is  very  common  in  lumbar  Pott's  disease ;  but  when  the  restric- 
tion  is  marked,  and  especially  if  it  be  unilateral,  a  deep  abscess 


44 


ORTHOPEDIC  SURGERY. 


may  be  suspected.  Such  unilateral  psoas  contraction  may  be 
demonstrated  by  placing  the  child  on  the  back,  allowing  the  limbs 
to  hang  over  the  edge  of  the  table,  when  the  unaffected  thigh 
will  drop  below  its  fellow  (Fig.  17). 

As  a  rule,  flexion  of  the  lumbar  spine  is  much  more  restricted 
in  the  early  stage  of  the  disease  than  is  extension ;  this  rigidity 
may  be  demonstrated  by  placing  the  child  on  its  hands  and  knees, 
and  lifting  it  from  the  floor,  when  the  body,  instead  of  bending 
over  tlie  supporting  hands,  retains  almost  its  original  contour 
(Fig.  18). 

As  has  been  stated,  even  at  an  early  stage  of  the  disease  one 
may  detect  often  a  slight  fulness  about  the  spinous  processes  or 


Fir:.  17. 


A  method  of  demouitrating  psoas  contraction. 


a  slight  irregularity  in  their  line,  about  which  the  muscular  spasm 
is  most  marked ;  this  indicates  the  exact  seat  of  the  disease. 
Deep  pressure  on  the  spinous  processes  at  this  point  will  often 
cause  pain,  and  sometimes  greater  elasticity  at  the  diseased  area 
may  be  demonstrated.  Except  in  the  hands  of  an  expert,  it  is, 
however,  a  test  of  comparatively  little  value ;  and  again  it  may 
be  mentioned  that  local  pain  and  local  sensitiveness  to  pressure 
on  the  spinous  processes  are  not  characteristic  signs  of  Pott's 
disease. 

Finally,  one  should,  examine  for  pelvic  abscess.  This  may  be 
suspected  when  unilateral  psoas  contraction  is  present  in  marked 
degree,  although  psoas  contraction  may  be  present  without  abscess 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


45 


and  abscess   may  be   unaccompanied  by  psoas   contraction  when 
the  substance  of  the  muscle  is  not  involved. 

The  typical  psoas  abscess,  as  pictured  and  described,  is  the 
fluctuating  tumor  that  suddenly  appears  on  the  inner  side  of  the 
thigh,  although  it  may  have  been  many  months  in  descending  to 
this  position  from  its  original  site.  Demonstrable  abscess  is 
present  at  some  time  in  at  least  50  per  cent,  of  the  cases  of  lumbar 
disease,  and  its  detection  is  a  matter  of  importance,  since  its  sub- 


FlG.  18. 


Disease  of  the  lumbar  region  before  the  stage  of  deformity.    A  test  for  rigidity 


sequent  behavior  will  often  materially  influence  the  treatment. 
The  child  is  placed  on  the  side,  the  thigh  is  flexed,  and  the  hand 
is  pressed  gently  down  into  the  loin  and  iliac  fossa.  Sometimes 
the  examination  will  be  made  easier  by  extending  the  limb  and 
thus  bending  the  spine  forward  toward  the  hand.  Often  in  this 
manner  one  can  make  out  the  peculiar,  sausage-like  thickening 
on  one  or  the  other  side  of  the  spine,  or  a  larger,  rounded  tumor 
in  the  iliac  fossa,  the  presence  of  which  would  not  otherwise 
have  been  suspected. 


46  ORTHOPEDIC  SURGERY. 

Diagnosis.  If  a  careful  physical  examination  were  made  in 
all  suspicious  cases,  by  one  at  all  familiar  with  the  ordinary 
symptoms  of  Pott's  disease,  the  held  for  differential  diagnosis 
would  be  small  indeed  -,  but  it  would  appear  that  such  examina- 
tions are  not  made  usually  by  the  physician  who  is  first  consulted. 
One  may  learn,  for  example,  that  the  child  has  been  circumcised 
because  of  pain  about  the  genitals,  or  because  of  weakness  of  the 
limbs,  supposed  to  be  due  to  "  reflex  irritation ;"  or  if  the  patient 
is  an  adult,  that  he  has  been  treated  for  sciatica,  rheumatism,  or 
strain,  long  after  the  evidence  of  Pott's  disease,  even  in  the 
angular  kyphosis,  would  have  been  apparent  had  the  back  been 
inspected. 

Pott's  disease  is  most  often  mistaken  for  some  one  of  the  fol- 
lowing affections  : 

Lumbago.  This  may  simulate  some  of  the  symptoms  of  Pott's 
disease  of  this  region,  but  it  is  an  acute  affection,  of  sudden  onset, 
usually  accompanied  by  local  pain  and  sensitiveness  of  the  muscles 
themselves. 

Strain  of  the  Back.  This  is  often  accompanied  by  stiffness  and 
pain  on  motion,  but,  like  lumbago,  its  onset  is  sudden  and  its 
cause  is  known.  The  pain  is  usually  localized  at  the  point  of 
injury ;  it  is  relieved  by  rest,  and  the  restriction  of  motion  is,  in 
great  degree,  voluntary.  In  Pott's  disease  the  pain  is  neuralgic; 
it  is  often  worse  at  night  and  the  rigidity  is  due  to  reflex  spasm. 

Sciatica.  The  pain  of  sciatica  is  most  often  unilateral:  it  is 
usually  confined  to  the  distribution  of  this  nerve,  which  is  often 
sensitive  to  pressure  throughout  its  course.  The  pain  of  Pott's 
disease,  if  it  is  referred  to  the  limbs,  is  usually  bilateral  and  the 
nerve  trunks  are  not  often  sensitive  to  pressure.  In  sciatica, 
movements  of  the  leg  that  cause  tension  on  the  nerve  are  often 
painful,  while  motion  of  the  spine  is  free,  or  but  slightly  restricted, 
the  reverse  of  the  symptoms  of  Pott's  disease.  It  is  true  that 
lateral  deviation  and  even  rigidity  of  the  lumbar  spine  are  some- 
times observed  in  cases  of  lumbosciatic  neuralgia  of  long  standing, 
but  if  the  latter  symptom  is  marked  the  diagnosis  may  be  regarded 
as  open  to  question. 

Sacro-iliac  disease  is  far  more  likely  to  be  mistaken  for  disease 
of  the  hip-joint  than  of  the  spine ;  the  pain  and  sensitiveness  are 
usually  localized  about  the  seat  of  disease  and  the  movements  of 
the  spine  are  not  restricted. 

Lumbago  and  sciatica  and  sacro-iliac  disease  are  extremely 
uncommon  in  childhood,  and  if  supposed  strains  or  injuries  of  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


47 


back  cause  persistent  symptoms,  the  appropriate  treatment  would 
be  similar  to  that  of  Pott's  disease ;  that  is  to  say,  fixation  and 
rest  of  the  suspected  part,  until  the  cause  of  the  symptoms  is  made 
clear. 

The  attitude,  characteristic  of  Pott's  disease  of  this  region,  the 
hollow  back  and  prominent  abdomen,  combined  with  the  waddling 


Fig.  19. 


Disease  of  the  lower  dorsal  region.    The  earliest  indication  of  deformity. 

gait,  may  be  simulated  by  bilateral  congenital  dislocation  of  the  hip, 
in  which  the  pelvis  is  suspended  at  a  point  behind  its  normal  posi- 
tion ;  l)ut  in  this  instance  the  gait  and  attitude  have  existed  since 
the  cliild  began  to  walk,  and  the  symptoms  of  bone  disease  are 
absent.  A  similar  attitude  is  sometimes  the  result  of  weakness  or 
])aralysis  of  tin;  muscles  of  the  back,  as,  for  example,  in  progressive 


48  ORTHOPEDIC  SUBQEBY. 

muscular  atrophy  or  pseudohypertrophic  muscular  paralysis.  In 
this  latter  affection  there  is  also  a  disinclination  to  stoop,  and  there 
may  be  rigidity  of  the  back,  symptoms  that  bear  a  superficial 
resemblance  to  Pott's  disease ;  but  as  there  are  no  other  signs  of 
disease  of  the  spine,  it  may  be  readily  excluded. 

When  psoas  contraction  is  present  in  lumbar  Pott's  disease,  the 
resulting  limp,  that  is  often  accompanied  by  pain  in  the  limb,  is 
almost  invariably  mistaken  for  a  symptom  of  hip  disease. 

Although  flexion  of  the  leg  caused  by  psoas  contraction  is  a 
common  accompaniment  of  Pott's  disease,  it  is  not  usually  an  early 
symptom ;  thus  the  history  will  probably  call  attention  to  symp- 
toms referable  to  the  spine,  that  have  preceded  it.  Again,  the 
limp  of  Pott's  disease  is  caused  simply  by  flexion  of  the  limb, 
a  limp  that  is  not,  as  in  joint  disease,  accompanied  by  pain  on 
functional  use.  When,  therefore,  in  the  physical  examination  the 
tension  of  the  contracted  iliopsoas  muscle  is  relieved  by  flexing 
the  thigh  still  further,  the  other  movements  of  the  hip,  abduction, 
adduction,  rotation,  and  flexion,  are  free  and  painless.  Thus,  hip 
disease,  in  which  all  motions  are  restrained  in  equal  degree  by  mus- 
cular spasm,  may  be  excluded  readily,  except,  perhaps,  in  infancy. 

Hip  Disease  in  Infancy.  At  this  susceptible  age  there  is  almost 
always  sympathetic  spasm  of  the  lumbar  muscles  in  acute  affections 
of  the  hip,  and  similar  spasm  of  the  hip  muscles  may  be  present 
in  Pott's  disease  of  the  lower  part  of  the  spine.  Several  examina- 
tions may  be  necessary  before  the  exact  location  of  the  disease  can 
be  determined,  and  in  doubtful  cases  the  application  of  a  temporary 
support  to  the  back  and  thigh,  such  as  a  spica-plaster  bandage  to 
relieve  the  sympathetic  spasm,  is  a  useful  aid  in  diagnosis. 

It  has  been  stated  that  extension  of  the  thigh  only  is  restrained 
by  psoas  contraction.  It  will  be  evident,  however,  that  the  pres- 
ence of  a  large  and  painful  abscess  in  the  pelvis  or  thigh  would 
limit  motion  in  other  directions  as  well ;  but  even  in  such  cases 
at  least  one  movement  is  unrestrained ;  thus  disease  within  the 
joint  may  be  excluded. 

Secondary  Hip  Disease.  In  Pott's  disease  of  long  standing, 
complicated  by  abscess,  in  which  the  tissues  about  the  joint  are 
infiltrated  or  traversed  by  discharging  sinuses,  secondary  infection 
of  the  hip-joint  is  not  an  unusual  complication.  In  such  cases, 
when  the  limb  is  distorted  and  when  motion  at  the  hip  is  limited 
by  the  infiltrated  and  contracted  tissues,  it  is  not  easy  to  determine 
the  presence  or  absence  of  joint  disease.  Doubtful  cases  of  this 
class  should  be  treated  symptomatically. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  49 

Pelvic  Abscess.  As  abscess  is  such  a  commou  complication  of 
Pott's  disease,  it  will  be  necessary  to  consider  abscesses  of  other 
origin,  that  may  cause  occasionally  symptoms  resembling  some- 
what those  of  disease  of  the  spine.  Such  are  the  perinephritie 
absoess,  and,  more  rarely,  that  of  appendieitis.  They  differ  from 
the  abscesses  of  Pott's  disease  in  that  they  are,  as  a  rule,  acute  in 
their  onset  and  are  accompanied  by  constitutional  symptoms  and 
by  local  pam  and  tenderness.  In  such  cases  the  motions  of  the 
spine  may  be  restrained,  but  the  restraint  is  in  great  degree  volun- 
tary, quite  different  from  the  rigidity  due  to  disease  of  its  sub- 
stance. It  is  true  that  the  pelvic  abscess  of  Pott's  disease  which 
has  become  infected  may  cause  constitutional  symptoms,  but  the 
history  of  the  disability  and  discomfort  that  must  have  preceded 
the  abscess,  together  with  the  probable  presence  of  deformity,  will 
make  the  diagnosis  clear.  Chronic  abscess  in  the  pelvis  of  other 
than  spinal  origin  may  be  the  result  of  disease  of  the  pelvic  bones, 
or  of  the  sacro-iliac  articulations,  or  of  the  hip-joint.  It  may  be 
caused  by  the  breaking  down  of  lymphatic  glands,  or  it  may  have 
its  origin  in  inflammation  about  the  uterine  appendages,  and  cases 
of  so-called  idiopathic  inflammation  and  suppuration  of  the  ilio- 
psoas muscle  have  been  described.  In  childhood,  chronic  abscesses 
in  this  locality  are  almost  always  tuberculous  in  character,  and  are 
caused  by  disease  of  bone,  either  of  the  spine  or  of  the  pelvis. 
Disease  of  the  spine  can  be  determined  usually  by  the  methods 
already  indicated,  but  if  the  abscess  is  of  other  origin  its  exact 
cause  can  be  decided  in  many  instances  only  by  an  operative  explo- 
ration. Abscesses  of  this  character,  of  slow  and  apparently  pain- 
less formation,  may  finally  cause  a  swelling  in  the  inguinal  region 
or  about  the  saphenous  opening,  that  in  the  adult  is  not  infre- 
quently mistaken  for  hernia.  In  practically  all  cases,  however, 
the  tumor  of  the  abscess  may  be  made  out  on  palpation  within  the 
pelvis,  and,  although  the  contents  of  the  external  sac  may  be  in 
part  forced  back  into  the  larger  reservoir,  its  reduction  is  very 
different  in  feeling  from  that  of  a  true  hernia. 

Peculiarities  of  Lumbar  Pott's  Disease  in  Infancy. 

Attention  has  been  called  repeatedly  to  the  great  importance  of 
careful  observation  of  the  postures  and  movements  of  the  patient, 
to  the  change  in  the  contour  of  the  spine,  and  particularly  to  the 
abnormal  lordosis  and  peculiar  attitude  of  overerectness  in  the 
early  stage  of  lumbar  disease.      But  the  description  of  attitudes  of 

4 


50  ORTHOPEDIC  SUBGEBY. 

standing  and  walking,  and  of  the  contour  of  the  spine,  which 
is  the  result  of  the  erect  posture,  does  not  apply  to  the  infant  in 
arms,  nor  need  the  spine  be  divided  into  contrasting  sections  for 
the  purpose  of  differential  diagnosis.  In  Pott's  disease  of  infancy 
the  muscular  spasm  is  usually  more  intense  and  its  extent  is  greater ; 
the  child  screams  when  it  is  moved  or  when  the  diapers  are 
changed.  Slight  irregularity  of  the  spinous  processes  indicating 
the  position  of  the  destructive  process  is  often  evident  and  abscess 
is  not  unusual.  There  is  usually  no  difficulty  in  determining  the 
presence  of  disease  even  in  very  early  cases,  but,  as  has  been  men- 
tioned, it  is  sometimes  difficult  to  decide  whether  the  lumbar  spine 
or  one  of  the  hip-joints  is  involved. 

Pott's  disease  of  infancy  may  be  mistaken  for  acute  rhachitis,  or 
scurvy.  The  symptoms  of  such  affections  are,  however,  not 
limited  to  the  spine,  but  involve  to  a  greater  or  less  degree  the  limbs 
and  joints,  indicating  that  the  discomfort  and  pain  are  due  to  a 
general,  not  to  a  local  disease. 

The  Rhachitic  Spine.  The  deformity  of  the  spine,  caused  by 
rhachitis,  is  not  infrequently  mistaken  for  the  kyphosis  of  Pott's 
disease. 

It  has  been  stated  that  when  in  early  infancy  the  child  is  placed 
in  the  sitting  posture  the  spine  bends  in  a  long,  posterior  curve, 
indicative  of  the  weakness  normal  at  this  age.  Such  a  curvature 
is  characteristic  also  of  acquired  weakness  and  particularly 
that  caused  by  rhachitis  in  early  childhood.  During  the  subacute 
stasre  of  general  rhachitis  the  child  that  has  never  walked  or  that 
has  "  lost  its  walk  "  sits  much  of  the  time  in  its  chair,  or  is  car- 
ried about  on  the  mother's  arm.  In  this  posture  the  spine  is 
bent  backward  and  a  curvature  of  the  lower  thoracic  and  lumbar 
region  is  habitual.  Soon  a  slight  projection  persists,  even  when 
the  child  is  lying  down ;  it  usually  increases  in  size  and  becomes 
more  resistant  if  its  exciting  cause  remains ;  thus,  a  somewhat 
rounded  and  rigid  posterior  curvature  of  the  dorsolumbar  portion 
of  the  spine  is  formed. 

The  diagnosis  from  Pott's  disease  should  be  made  without  diffi- 
culty, because  the  evidences  of  general  rhachitis  are  always  present, 
and  because  the  deformity  is  almost  as  much  to  be  expected  as  would 
be  distortions  of  the  legs  were  the  child  walking.  If  the  patient 
is  placed  in  its  habitual  sitting  posture  it  will  be  seen  that  the 
deformity  is  simply  an  exaggeration  of  a  normal  attitude.  In  this 
attitude  the  patient  remains  contentedly  for  an  indefinite  time, 
whereas  if  Pott's  disease  were  present  the  child  would  lie  on  its 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  51 

back  or  abdomen.  The  projection  is  rounded,  not  angular,  and 
if  the  patient  be  placed  in  the  prone  posture  the  projection  may  be 
reduced,  in  great  part,  by  raising  the  thighs  while  gentle  j)ressure 
is  exerted  upon  the  kyphosis.  Finally,  although  such  extension 
and  pressure  may  cause  discomfort,  there  is  complete  absence  of 
the  muscular  spasm  characteristic  of  Pott's  disease. 

It  may  be  stated,  then,  that  the  rhachitic  deformity  is  a  rounded 
curvature  of  the  lower  part  of  the  spine.  Its  cause  is  weakness 
and  habitual  posture.  The  rigidity  depends  upon  the  duration  of 
the  deformity.  The  pain,  if  the  rhachitis  be  acute,  is  general  and 
it  is  easily  explained  by  the  sensitive  condition  of  the  bones  and 
joints.  It  is  true  that  rhachitis  and  tuberculous  disease  of  the 
spine  may  be  combined,  but  in  such  rare  instances  the  symptoms 
of  the  more  serious  local  disease  will  make  themselves  evident  as 
distinct  from  those  of  the  general  weakness. 

Recapitulation.  The  more  characteristic  symptoms  of  disease 
of  the  dorsolumbar  region  may  be  summed  up  as  follows  : 

Increased  lordosis  or  overerectness  and  a  prominent  abdomen ; 
a  cautious,  constrained,  or  waddling  gait;  less  often  a  lateral 
inclination  of  the  body  or  a  limp  caused  by  psoas  contraction. 

Stiffness  of  the  spine,  which  makes  bending  or  turning  the  body 
difficult. 

Pain,  referred  to  the  back,  to  the  inguinal  region,  or  to  the 
thighs,  and  in  more  advanced  cases  the  characteristic  deformity. 

Diagnosis.  The  attitude  may  be  simulated  by  congenital  dis- 
location of  the  hips  and  by  pseudohypertrophic  muscular  paralysis. 

The  limp  may  be  mistaken  for  that  of  hip  disease. 

The  pain  and  stiffness  for  sciatica,  rheumatism,  lumbago,  or 
injury. 

The  abscess  is  to  be  distinguished  from  those  from  other  sources. 

In  young  infants  the  symptoms  may  be  simulated  by  hip  disease 
and  by  acute  rhachitis  or  scurvy. 

Finally,  the  deformity  of  the  subacute  form  of  rhachitis  is  to  be 
distinguished  from  that  symptomatic  of  bone  destruction. 


Disease  of  Thoracic  Region  of  the  Spine. 

The  normal  motion  of  this  section  of  the  spine,  which  inclndes 
the  third  and  tenth  vertebrae,  is,  as  compared  with  those  above 
and  below  it,  slight ;  thus,  disease  of  this  region  may  not  interfere 
to  a  noticeable  degree  with  the  general  function  of  the  spine. 

As  this  part  of  the  colunui  curves  backward,  the  deformity,  often 


52  ORTHOPEDIC  S UB GEB  Y. 

unattended  by  severe  symptoms,  is  not  infrequently  mistaken  for 
round  shoulders  (Fig.  20).  It  seems  probable,  also,  because  of 
the  normal  backward  curve,  and  because  of  the  leverage  exerted  by 
the  weight  of  the  head  and  arms,  that  deformity  quickly  follows 
disease.  At  all  events,  patients  are  not  often  seen  before  it  is 
present,  so  that  diagnosis  is  usually  evident  on  inspection  of  the 
patient. 

The  attitudes  are  not  especially  significant.  If  the  lower  part 
of  the  region  is  involved,  and  if  the  disease  be  at  all  acute,  they 
are  similar  to  those  of  disease  of  the  lower  region,  viz.,  erectness, 
the  peculiar,  cautious,  in-toeing  step,  and  the  disinclination  to 
bend  the  body  forward  (Fig.  19). 

If,  on  the  other  hand,  the  upper  part  is  affected,  the  attitude  is 
often,  particularly  in  young  children,  one  of  weakness ;  there  is  a 
slight  forward  inclination  of  the  body,  the  head  being  tilted  back- 
ward or  inclined  toward  one  side,  and  a  peculiar  shrugging, 
squareness,  and  elevation  of  the  shoulders  is  often  noticeable 
(Fig.  21).  In  many  instances  the  apparent  elevation  of  the 
shoulders  is  in  reality  caused  by  the  deformity,  which  shortens  the 
neck  and  lowers  the  head  (Fig.  23). 

In  this  connection  it  should  be  mentioned  that  one  of  the 
secondary  effects  of  the  disease,  the  so-called  pigeon  breast,  is, 
not  infrequently,  noticed  by  the  parent  before  the  angular  deform- 
ity of  the  spine.  In  the  pigeon  breast  of  Pott's  disease  the  for- 
ward inclination  of  the  spine  causes  a  flattening  of  the  upper  part 
of  the  chest,  while  the  sternum  sinks  downward  and  becomes 
prominent ;  thus,  the  anteroposterior  diameter  of  the  thorax  is  in- 
creased, and  it  is  compressed  from  side  to  side,  resembling  very 
closely  the  deformity  of  rhachitis.  As  the  pigeon  breast  of  Pott's 
disease  is  always  secondary  to  the  spinal  deformity,  its  cause,  of 
course,  becomes  apparent  on  examining  the  back. 

Of  the  early  symptoms  of  disease  of  the  thoracic  region,  pain 
and  labored  or  "  grunting"  respiration  are  the  most  characteristic. 
Pain  referred  to  the  abdomen  and  to  the  front  and  sides  of  the 
chest  is  usually  an  early  and  often  a  constant  symptom ;  thus, 
persistent  "stomach-ache"  in  a  child  should  always  lead  to  an 
examination  of  the  spine.  A  ''spasm  of  pain"  is  sometimes 
excited  by  lateral  compression  of  the  chest,  as  when  the  child  is 
lifted  suddenly  by  the  parent. 

Of  much  greater  importance,  however,  is  the  labored  or  grunt- 
ing respiration,  which,  indeed,  is  almost  pathognomonic  of  Pott's 
disease.      This    ' '  grunting "    is   caused   by  the  interference  with 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


53 


respiration,  more  particularly  with  the  normal  rhythmical  move- 
ments of  the  ribs.  The  restraint  is,  in  part,  due  to  muscular  spasm 
and  deformity  and  in  part  to  the  voluntary  effort  of  the  patient. 
The  inspiration  is  quick  and  shallow,  in  great  degree  diaphrag- 
matic, and  expiration  is  accompanied  by  a  sigh  or  grunt.  This  is 
caused  apparently  by  a  momentary  closure  of  the  larynx  to  resist 


Fig.  20. 


Fig.  21. 


Pott's  disease  of  the  middle  dorsal  region  at 
an  early  stage,  showing  slight  increase  of  the 
dorsal  kyphosis,  without  noticeable  change  in 
the  attitude.    Contrast  with  Fig.  21. 


Disease  of  the  upper  dorsal  region. 
Characteristic  attitude. 


the  escape  of  air  and  thus  sudden  motion  of  the  chest  walls. 
Grunting  respiration  is,  of  course,  an  evidence  of  the  more  acute 
type  of  disease,  but  even  in  mild  cases  in  children  it  will  be  noticed 
when  th(i  patient  is  fatigued  or  during  play. 

An  irritating,  aim/ess  cough  is  often  a  symptom  of  disease  of  the 


54 


ORTHOPEDIC  SURGERY. 


Fig.  22. 


upper  dorsal  region,  and  spasmodic  attacks  resembling  asthma  are 

not  uncommon. 

In  most  instances  the  characteristic  angular  kyphosis  will  appear 

on  examination,  and  in  the  exceptional  cases  in  which  deformity 

is  absent,  a  slight  change  in  con- 
tour will  be  apparent  when  the 
patient  is  bent  forward.  In  place 
of  the  long,  regular  curve  of  the 
normal  spine  a  point  where  two  dis- 
tinct outlines  unite  will  be  observed 
—  one  of  which  may  be  curved, 
while  the  other  is  practically  straight 
(Fig.  7). 

The  presence  of  muscular  spasm 
may  be  shown  by  sudden  move- 
ment of  the  spine,  and  it  may  also 
be  demonstrated  in  children  by  rais- 
ing the  legs  and  swaying  the  body 
from  side  to  side,  as  illustrated  in 
the  preceding  section  (Fig.  15). 
The  change  in  the  rhytlim  of  res- 
piration has  been  mentioned  already. 
A.lthough  the  respiratory  movement 
of  the  entire  thorax  is  lessened  in 
range,  the  restraint  does  not  affect 
all  the  ribs  equally;  those  that 
articulate  with  the  diseased  verte- 
brae are  often  nearly  motionless, 
while  the  movement  of  those  at  a 
distance  from  the  disease  may  ap- 
proach the  normal. 

In  tracing  the  neuralgic  j^ain  to 
its  origin  the  sharp,  downward  in- 
clination of  the  ribs  must  be  borne 
pain   in   the    ' '  stomach  "  must   be 


Marked  lateral  deviation  of  the  spine 
with  rotation.  Deformity  at  the  eighth 
dorsal  vertebra. 


in   mind;  thus,  the   cause  of 

looked  for  between  the  shoulder  blades. 

As  in  the  lumbar  region,  slight  lateral  deviation  of  the  spine  is 
not  uncommon,  and  it  may  be  accompanied  by  a  noticeable  twist 
or  rotation  so  that  the  ribs  on  one  side  project  slightly  backward 
(Fig.  22). 

In  this  region  of  the  spine  the  spinal  cord  is  more  often  involved 
than  in  disease  of  other  sections  ;  thus,  an  awkward,  stumbling  gait 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


55 


and  finally  a  ^Moss  of  walk"  maybe  the  symptoms  that  first 
attract  attention.  The  paralysis  of  Pott's  disease  and  its  differen- 
tial diagnosis  are  considered  in  more  detail  elsewhere. 

Abscess  as  a  complication  of  disease  of  the  thoracic  region  cannot 
be  demonstrated  by  palpation  unless  it  has  found  an  outlet 
between  the  ribs,  but  percussion  will  often  show  an  area  of  dulness 
or  flatness,  extending  from  the  diseased  vertebrae  toward  the  lateral 
aspect  of  the  chest.      This  is  due  in  part,  however,  to  the  inflam- 

Frc.  23. 


Double  psoas  contraction  of  an  extreme  degree  and  paralysis.     The  arms  used  as  supports. 

matory  thickening  of  the  tissues  in  the  neighborhood.  In  rare 
instances  the  abscess  may  press  directly  upon  the  trachea  or  bronchi 
and  cause  spasmodic  attacks  of  dyspnoea  resembling  asthma. 

Diagnosis.  It  is  hardly  necessary  to  mention  the  list  of  affec- 
tions that  may  cause  pain  in  the  chest  or  abdomen  ;  it  is  sufficient 
to  state  that  such  symptoms  always  require  a  physical  examina- 
tion. The  same  statement  applies  to  irregular  respiration,  to 
cough,  and  to  so-called  asthma. 


56  ORTHOPEDIC  SURGERY. 

Occasionally  tuberculous  disease  of  the  dorsal  spine  in  adoles- 
cence is  practically  painless,  and  the  resulting  deformity  is  rather 
rounded  than  angular,  so  that  it  may  be  mistaken  for  round 
shoulders.  "Round  shoulders"  is,  however,  as  a  rule,  of  long 
duration.  The  exciting  cause  or  causes  of  postural  deformity,  in 
occupation  or  otherwise,  are  indicated  often  by  the  history.  The 
rigidity  is  less  marked  than  in  Pott's  disease,  and  neuralgic  pain 
is  absent. 

The  situation  and  shape  of  the  rhachitic  kyphosis  has  been 
described.  It  should  be  evident  that  a  more  or  less  angular  pro- 
jection in  the  upper  part  of  the  spine  could  not  be  rhachitic ;  and 
yet  because  of  the  absence  of  pain  this  diagnosis  is  made  not  infre- 
quently, and  as  a  consequence  the  activity  of  the  tuberculous  dis- 
ease may  be  increased  by  massage  and  exercises. 

Lateral  deviation  of  the  spine  as  a  symptom  of  disease  hardly 
could  be  mistaken  for  the  ordinary  rotary-lateral  curvature,  in 
which  pain  and  muscular  rigidity  are  absent. 

Acute  affections  within  the  chest,  pleurisy,  pneumonia,  and 
empyema,  are  sometimes  accompanied  by  lateral  deviation  of  the 
spine,  but  the  sudden  onset  and  the  constitutional  and  local 
symptoms  that  accompany  such  affections  should  make  the  cause 
of  the  deformity  and  pain  evident.  It  is  because  these  cases  are 
sometimes  sent  to  orthopedic  clinics  for  braces  that  they  seem 
worthy  of  mention. 

The  abscesses  in  this  region,  as  has  been  mentioned,  cause 
usually  dulness  or  flatness  on  percussion  of  the  chest,  and  within 
this  area  friction  sounds  and  rJiles  may  be  heard.  The  tubercu- 
lous fluid  may  remaia  iudeflnitely  in  the  posterior  mediastinum 
and  the  area  of  flatness  may  extend  beyond  the  axillary  line,  yet 
it  may  give  rise  to  no  symptoms.  If  the  diagnosis  of  Pott's  dis- 
ease had  not  been  made  or  if  the  presence  of  the  abscess  had  not 
been  determined  by  the  previous  physical  examination,  it  might 
be  mistaken,  during  an  acute  exacerbation  of  the  disease  or 
constitutional  disturbance  from  other  cause,  for  pleurisy  or  empy- 
ema or  even  for  phthisis.  In  all  cases,  therefore,  a  careful  exami- 
nation of  the  chest  should  be  made  from  time  to  time  in  order 
that  the  presence  or  absence  of  abscess  may  be  recorded. 

Recapitulation.  Pott's  disease  of  this  region  is  often  insidious 
in  its  onset,  causing  no  positive  symptoms  before  the  stage  of 
deformity. 

Its  most  characteristic  symptoms  are  pain  referred  to  the  front 
and  sides  of  the  body  and  the  grunting  respiration. 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


57 


If  the  disease  is  progressive^  the  characteristic  symptoms  of 
Pott's  disease — weakness  and  rigidity — are  present.  The  atti- 
tude, when  the  disease  is  in  the  lower  thoracic  region,  rescmVjles 
that  of  lumbar  disease ;  if  the  upper  part  is  affected  the  head  is 
tilted  somewhat  backward  and  the  shoulders  appear  to  be  ele- 
vated. 

In  difi'ereutial  diagnosis  one  will  consider  the  significance  of 
pain,  cough,  or  embarrassed  respiration,  and  the  affections  for 
which  abscess  or  paralysis  might  be  mistaken.  Also,  round 
shoulders,  rhachitic  deformity,  and  lateral  deviation  of  the  spine 
as  distinguished  from  the  kyphosis  of  Pott's  disease. 

2.  The  Upper  Region,  The  upper  region  of  the  spine,  which 
includes  the  cervical  and  two  of  the  dorsal  vertebrse,  corresponds 

Fig.  24. 


Cervical  disease  witli  abscess.    Characteristic  attitude. 

in  freedom  of  movements  and  in  its  contour  to  the  lumbar  region. 
For  the  purpose  of  study  it  must  be  divided  into  two  parts.  Of 
these,  the  superior  or  occipito-axoid  section  is  peculiar,  in  that  it 
contains  no  vertebral  body  or  intervertebral  cartilage,  and  in  that 


58  OB THOPEDIC  S  UB GEB  Y. 

the  movements  of  the  head  are  carried  out  in  special  joints  and 
are  controlled  by  special  muscles. 

Disease  at  this  point  is  especially  dangerous,  because  displace- 
ment or  fracture  of  the  weakened  vertebrae  may  cause  sudden 
death  by  pressure  on  the  vital  centres. 

Occipito-axoid  disease  is  uncommon,  and  it  is  relatively  more 
frequent  in  adult  life  than  in  childhood. 

Symptoms.  In  a  typical  case  the  symptoms  are  neuralgic  pain 
radiating  over  the  back  and  sides  of  the  head,  following  the  dis- 
tribution of  the  auricular  and  occipital  nerves.  The  neck  is  stiff 
and  the  head  may  be  fixed  in  the  median  line,  the  chin  being 
somewhat  depressed,  but  it  is  more  often  tilted  to  one  side,  simu- 
lating the  attitude  of  torticollis  (Fig.  24). 

The  attitude  and  appearance  of  the  patient,  when  normal  move- 
ment of  the  neck  is  restrained  by  a  painful  disease,  is  character- 
istic; the  eyes  follow  one,  or  the  body  is  turned,  when  the 
attention  of  the  patient  is  attracted.  The  patient  moves  carefully, 
in  order  to  avoid  jar ;  often  the  chin  is  instinctively  supported  by 
the  hand,  and  a  favorite  attitude  is  one  in  which  the  patient  sits 
with  the  elbows  on  a  table,  the  hands  supporting  the  head 
(Fig.  25).  If  the  attempt  is  made  to  raise  the  chin,  or  to  rotate 
the  head,  the  patient  seizes  the  hands  of  the  examiner,  and,  it 
may  be,  screams  in  apprehension.  There  may  be  slight  bulging 
and  thickening  of  the  tissues  at  the  seat  of  disease.  The  affected 
vertebrae  are  usually  sensitive  to  direct  pressure,  and  not  infre- 
quently deep  fluctuation  in  the  suboccipital  triangle  can  be  made 
out. 

The  atlo-axoid  junction  lies  just  behind  the  posterior  wall  of 
the  pharynx,  on  a  line  with  the  upper  teeth.  Here  abscess  often 
presents  itself,  occasionally  early  in  the  course  of  the  disease, 
causing  symptoms  characteristic  of  obstruction,  such  as  snoring, 
change  in  the  quality  of  the  voice,  difficulty  in  swallowing,  or 
spasmodic  attacks  of  so-called  croup.  When  abscess  is  present 
and  when  the  disease  is  at  all  acute,  the  reclining  posture  some- 
times aggravates  the  symptoms,  so  that  "  getting  the  child  to 
bed  "  is  often  a  tedious  and  difficult  task. 

In  certain  cases  one  can  determine  whether  the  disease  is  of 
the  occipito-atloid  or  of  the  atlo-axoid  articulation,  but,  as  both 
joints  are  to  a  great  extent  controlled  by  the  same  muscles,  this 
is  often  impossible. 

The  uppermost  joint,  that  between  the  atlas  and  occiput,  per- 
mits the  nodding  movement  of  the  head,  or  flexion  and  extension 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


59 


on  the  spine ;  while  the  atlo-axoid  joint  permits  rotation  of  the 
atlas  about  the  axis  to  the  extent  of  about  30°  in  either  direction. 
If  the  disease  be  in  the  upper  joint  the  nodding  movements  will 
be  more  restricted  than  those  of  rotation,  and  viee  versa.  The 
motion  of  the  cervical  region  is  very  free  ;  so  that  to  make  the 
test  one  must  grasp  the  neck  firmly  in  order  to  restrain  motion 
except  in  the  joint  under  examination.  Because  of  this  freedom 
of  movement,  restriction  of  motion  of  the  upper  articulations 
is  often  overlooked  when  the  disease  is  of  the  subacute  variety. 

Fig.  25. 


Cervical  disease.    A  characteristic  attitude. 

The  Lower  Cervical  Region.  The  symptoms  of  disease  of  the 
lower  cervical  section,  although  similar  in  character,  are  often  less 
marked  than  those  of  the  upper  region.  The  cervical  spine 
becomes  straighter,  and  often  a  slight  backward  projection  or 
thickening  indicates  the  position  of  the  disease.  The  head  is 
usually  turned  to  one  side  by  spasm  of  the  lateral  muscles  in  an 
attitude  of  wryneck  (Fig.  26).     The  pain  is  referred  to  the  neck, 


60 


ORTHOPEDIC  SURGERY. 


to  the  sternal  region,  or  down  the  arras,  following  the  clistribntion 
of  the  brachial  plexus. 

In  the  more  advanced  cases  one's  attention  may  be  attracted 
to  the  cervical  region,  because  the  neck  seems  short  and  because 
the  head  is  tilted  backward.  The  entire  back  shows  a  com- 
pensatory flattening,  yet  no  deformity  is  apparent  until  the 
occiput  is  raised  and  drawn  forward,  when  a  shelf-like  projection 
may  be  felt,  at  what  appears  to  be  the  top  of  the  spine,  but  which 
is  really  an  angular  deformity  at  the  third  or  fourth  vertebra. 

This  emphasizes  the  importance  of  a  careful  observation  of  the 
contour  of  the  spine,  and  the  necessity  of  explaining  to  one's  self 
every  change  from  the  normal  that  may  be  noticed. 


Fig.  26. 


Disease  of  the  middle  cervical  region  at  an  early  stage. 

Disease  at  the  cervicodorsal  junction,  resembles  in  its  symptoms 
that  of  the  upper  dorsal  region.  The  head  is  usually  tilted  back- 
ward (Fig.  21)  or  it  may  be  turned  to  one  side.  Disease  at  this 
point  is  often  subacute  in  character,  and  paralysis  from  implica- 
tion of  the  spinal  cord  sometimes  appears  before  deformity  is 
apparent.     Occasionally  irregularity  of  the  pupils  is  present. 

The  spinous  process  of  the  seventh  cervical  or  first  dorsal  ver- 
tebra is  often  prominent  (vertebra  prominens)  in  normal  indi- 
viduals, and  it  may  be  mistaken  for  the  deformity  of  disease, 
especially  when  pain  about  this  point  is  a,  symptom,  as  in  hys- 
terical or  hypersesthetic  persons.  If  such  projection  is  symp- 
tomatic of  disease  there  is  almost  always  a  slight  compensatory 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  61 

flattening  of  the  spine  below  the  point  and  a  certain  degree  of 
rigidity  of  the  surrounding  muscles. 

Diagnosis.  As  stiffness  and  distortion  of  the  neck  are  the 
most  prominent  symptoms  of  disease  of  this  region,  one  must  con- 
sider first  the  forms  of  torticollis  for  which  it  might  be  mistaken. 
In  typical  torticollis,  the  distortion  of  the  head  is  caused  almost 
invariably  by  contraction  of  the  muscles  supplied  by  the  spinal 
accessory  nerve,  the  sternomastoid,  and  trapezius ;  thus,  the  chin 
is  slightly  elevated  and  turned  away  from  the  contracted  muscle. 

Congenital  torticollis,  which  has  existed  from  birth,  is  not 
accompanied  by  pain,  and  it  could  hardly  be  mistaken  for  a 
symptom  of  disease. 

Acute  rheumatic  torticollis,  "  stiff  neck,"  is  sufficiently  common 
to  be  familiar  in  its  characteristics.  It  is  of  sudden  onset,  '^  in  a 
single  night ;"  the  affected  muscles  are  sensitive  to  pressure ;  the 
course  of  the  affection  is  short,  and  it  is  of  comparative  insig- 
nificance. 

A  more  persistent  form  of  acute  torticollis,  accompanied  by 
muscular  spasm  and  by  local  tenderness,  sometimes  accompanies 
enlarged  or  suppurating  cervical  glands;  it  may  follow  ''ear- 
ache," "  tonsillitis,"  "  sore-throat,"  or  any  form  of  irritation 
about  the  pharynx.  This  form  of  wryneck  is  not  only  very 
painful,  but  it  may  persist  indefinitely,  and  permanent  deformity 
may  result.  The  onset  is  usually  sudden ;  the  pain  and  tender- 
ness are  local,  and  are  confined,  as  a  rule,  to  the  contracted  part. 
The  sternomastoid  and  trapezius  muscles  are  most  often  involved  ; 
thus,  the  wryneck  is  typical.  If  the  tension  be  relaxed  by 
inclining  the  head  toward  the  contracted  muscles,  motion  of  the 
spine  itself  will  be  found  to  be  free  and  painless ;  but  if  traction 
be  made  on  the  contracted  muscles  it  causes  discomfort,  and  it  is 
usually  resisted  by  the  patient. 

In  disease  of  the  occipito-axoid  region  the  distortion  of  the 
head  is,  by  no  means,  typical  of  sternomastoid  contraction  ;  it 
may  be  tilted  up  or  down  or  laterally  to  an  exaggerated  degree. 
In  other  words,  the  wryneck  of  Pott's  disease  is  an  irregular 
distortion,  because  it  is  not  dependent  on  the  contraction  of  a  par- 
ticular muscle  or  muscular  group.  "  In  torticollis  the  chin  is 
turned  away  from  the  contracted  muscle,  while  in  Pott's  disease 
it  is  turned  toward  the  contracted  muscle."  This  is  an  axiomatic 
expression  of  the  fact  that  the  distortion  of  the  head  symptomatic 
of  atlo-axoid  disease  depends,  in  great  degree,  upon  the  spasm 
of  the  small  muscles  that  directly  control  these  joints,  the  recti 


62  OR  THOPEDIC  S  UB  GEB  Y. 

and  obliqui,  and  not  directly  npon  the  contraction  of  the  sterno- 
mastoid  muscle,  as  in  the  ordinary  form  of  wryneck.  Again, 
the  contraction,  symptomatic  of  Pott's  disease,  of  this  or  other 
regions,  is  the  result  of  muscular  spasm,  a  muscular  spasm  that 
prevents  painful  motion.  If  the  head  be  grasped  firmly  by 
the  hands  and  if  gentle  traction  is  made,  the  muscular  spasm 
relaxes  and  the  patient  experiences  a  sensation  of  comfort.  If 
similar  traction  is  made  upon  the  contracted  muscles  of  acute  wry- 
neck, the  pain  is  increased  and  the  patient  protests. 

In  disease  of  the  middle  cervical  region,  however,  the  distor- 
tion due  to  the  reflex  muscular  spasm  may  resemble  closely  that 
of  simple  torticollis,  particularly  if  the  latter  is  caused  by  the 
irritation  of  inflamed  or  suppurating  glands.  For,  in  such  cases, 
there  is  usually  much  sensitiveness  to  manipulation,  with  more 
or  less  general  muscular  spasm,  and  diagnosis  may  be  impossible 
until  apparatus  has  been  applied  to  rest  the  part  and  to  correct 
the  deformity. 

As  has  been  stated,  the  head  may  be  tilted  backward  to  com- 
pensate for  deformity  in  the  middle  cervical  region,  and  in  some 
instances  it  may  be  drawn  backward  by  spasm  of  the  posterior 
muscles.  Such  a  case  might  be  mistaken  for  cervical  opisthotonos, 
or  posterior  torticollis,  which  is  sometimes  seen  in  young  infants 
suffering  from  exhausting  diseases,  basilar  meningitis,  and  the 
like.  In  such  conditions,  however,  the  characteristic  symptoms 
of  Pott's  disease  are,  of  course,  absent. 

The  opposite  attitude,  viz.,  a  forward  droop  of  the  head  due  to 
Aveakness  of  the  trapezii  muscles,  is  not  uncommon  as  a  sequence 
of  diphtheria  or  other  forms  of  contagious  disease.  This  droop 
may  be  accompanied,  also,  by  spasm  of  one  of  the  sternomastoid 
muscles  and  by  pain.  In  such  cases  the  history  of  the  preceding 
affection,  the  weakness  or  paralysis  of  other  parts,  as  of  the  soft 
palate,  the  muscles  of  accommodation  of  the  eyes  and  the  like, 
together  with  the  general  bodily  weakness  that  the  patients  often 
present,  should  make  the  diagnosis  clear. 

Injury  to  the  upper  segment  of  the  spine,  a  sprain,  contusion, 
or  fracture,  unless  efficiently  treated,  may  cause  symptoms  resem- 
bling very  closely  those  of  tuberculous  disease;  for  example, 
pain,  radiating  over  the  back  of  the  head,  rigidity  and  deformity 
of  the  neck,  and  even  infiltration  and  local  tenderness  about  the 
injured  part.  Such  cases,  when  seen  several  weeks  or  months 
after  the  accident,  are  puzzling,  because  one  may  be  in  doubt 
whether  the  symptoms  were  caused  by  a  simple  injury  or  whether 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  63 

tuberculous  infection  may  have  followed  or  preceded  it.  In  such 
cases  a  positive  diagnosis  cannot  be  made  until  the  effect  of  rest 
and  protection  has  been  observed — that  is  to  say,  suspicious  cases 
should  be  treated  as  one  would  treat  actual  disease.  If  the  case 
is  simply  one  of  injury  recovery  will  be  rapid  and  complete, 
while  if  disease  be  present  the  symptoms  only  will  be  relieved. 

The  occipito-axoid  articulation  may  be  involved  in  acute 
articular  rheumatism  or  in  chronic  rheumatoid  arthritis.  If  the 
manifestations  are  general  in  character  the  diagnosis  is,  of  course, 
easily  made  ;  but  occasionally  the  joints  at  the  upper  extremity  of 
the  spine  may  be  the  seat  of  what  appears  to  be  an  infectious 
arthritis,  in  which  the  symptoms  are  of  sudden  onset  and  are 
sometimes  combined  with  fever  and  constitutional  disturbance, 
and  in  which  no  other  joint  is  involved.  The  sudden  onset  and 
rapid  recovery  are  the  diagnostic  points. 

Abscess  in  the  cervical  region  is  a  secondary  symptom,  and 
although  the  change  in  the  voice  or  the  difficulty  in  breathing  or 
swallowing  may  be  the  most  noticeable  symptoms,  yet  they  are 
always  accompanied  by  some  of  the  characteristic  signs  of  Pott's 
disease. 

Whenever  the  diagnosis  of  cervical  disease  is  made  one  should 
examine  the  throat,  and  whenever  a  chronic  retropharyngeal 
abscess  is  present  one  should  look  for  the  symptoms  of  Pott's 
disease. 

The  diagnosis  of  the  retropharyngeal  abscess  can  be  made  only 
by  inspection  and  palpation ;  therefore,  one  need  only  mention 
the  fact  that  symptoms  of  obstruction  in  the  throat,  similar  to 
those  of  abscess,  may  be  caused  by  adenoid  growths  and  by 
enlarged  tonsils. 

Retropharyngeal  abscess  is  by  no  means  always  symptomatic 
of  Pott's  disease.  It  may  be  one  of  the  sequelas  of  contagious 
disease  or  a  complication  of  pharyngitis.  It  is  then  rapid  in  its 
onset  and  is  not  accompanied  by  the  symptoms  of  Pott's  disease. 

Recapitulation.  If  the  disease  is  of  the  upper  or  occipito- 
axoid  region  the  head  is  usually  fixed  in  an  attitude  of  deformity, 
which  is  sometimes  slight  and  sometimes  extreme. 

If  the  disease  is  of  the  middle  region,  the  attitude  more  often 
resembles  that  of  ordinary  torticollis.  In  the  lower  region  there 
is  often  no  marked  spasm  of  muscles,  but  the  head  inclines  back- 
ward or  toward  one  shoulder. 

The  contour  of  the  cervical  spine  changes  as  the  disease 
progresses ;  the  normal  anterior  curvature  is  obliterated  ;  thus. 


64  ORTHOPEDIC  S  UR  GER  Y. 

the  head  is  pushed  forward,  while  the  dorsal  section  of  the  spine 
becomes  flat  or  even  incurvated  in  compensation.  The  seat  of  the 
disease  is  often  shown  by  an  area  of  thickening  or  local  tender- 
ness to  deep  pressure. 

Disease  of  the  joints  of  the  upper  or  occipito-axoid  section  is 
often  acute  in  onset,  in  some  instances  apparently  a  form  of 
synovial  tuberculosis,  and  abscess  is  a  very  frequent  complication. 

Differential  diagnosis  of  disease  in  this  region  will  include  the 
consideration  of  the  various  forms  of  wryneck,  cervical  opisthot- 
onos, diphtheritic  paralysis,  and  injury.  Secondary  abscess 
must  be  distinguished  from  simple  retropharyngeal  abscess  and 
from  other  forms  of  obstruction  in  the  throat. 

Diagnosis  in  General.  Weakness  and  the  so-called  "  loss  of 
walk  "  are  well-known  symptoms  of  Pott's  disease,  and  on  this 
account  children  suffering  from  different  forms  of  weakness  or 
paralysis  are  often  sent  to  orthopedic  clinics  for  the  treatment  of 
"  spine  disease." 

Certain  forms  of  paralysis  bear  a  superficial  resemblance  to 
some  of  the  symptoms  of  Pott's  disease ;  for  example,  'pseudo- 
hypertrophic muscular  parali/sis  to  the  attitude  caused  by  disease 
of  the  lumbar  region,  and  diphtheritic  paralysis  to  that  of  the 
dorsal  region.  Spastic  paralysis,  of  cerebral  origin,  resembles 
somewhat  the  paralysis  of  Pott's  disease,  but  it  may  be  differen- 
tiated by  the  absence  of  pain,  by  the  history,  and  by  what  is 
apparent  in  most  cases,  the  mental  impairment. 

Primary  spastic  spinal  paraplegia  resembles  the  paralysis  of 
Pott's  disease  more  closely,  but  here,  again,  the  essential  symp- 
toms of  a  destructive  disease  of  the  spine  are  absent. 

The  contractions  combined  with  the  weakness  and  pain  that 
sometimes  follow  cerebrospinal  meningitis  may  be  mistaken  for 
the  symptoms  of  bone  disease,  but  are,  as  a  rule,  readily  explained 
by  the  history  of  the  case. 

Forms  of  organic  disease  of  the  spine  other  than  tuberculosis, 
as,  for  example,  malignant  disease,  syphilis,  spondylitis  defor- 
mans and  the  like,  are  described  in  Chapter  II. 

The  list  of  affections  that  has  been  considered  in  the  differen- 
tial diagnosis  is  a  long  one,  but  it  has  been  made  up  from  actual 
experience.  Most  of  the  mistakes  in  diagnosis  may  be  explained 
by  carelessness  or  ignorance,  or  because  of  insufficient  opportunity 
for  examination ;  but  in  the  earliest  stages  of  the  disease  repeated 
examinations  and  even  tentative  treatment  may  be  necessary 
before  the  diagnosis  is  confirmed. 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


65 


The  Roentgen  Ray  Photography  as  a  Means  of  Diagnosis.  The 
Roentgen  ray  is  of  comparatively  little  importance  from  the  diag- 
nostic standpoint,  but  it  may  be  of  value  as  a  means  of  determining 
the  exact  extent  of  the  disease.  If  the  negative  is  well  defined, 
the  diseased  vertebra?  are  seen  to  be  irregular  in  outline,  or  they 
may  be  lost  in  a  peculiar  blur.  By  counting  from  above  and 
below  the  exact  extent  of  the  disease  may  be  made  out,  but  infer- 
ences as  to  its  character  and  quality  must  be  made  from  the 
rational  and  physical  signs  (Fig.  34). 

The  Record  of  the  Case.  The  history  and  the  results  of  the 
examination  of  the  patient  should  be  recorded  somewhat  in  the 
following  order  : 

1.  The  family  and  the  personal  history. 

2.  The  history  of  the  disease,  with  especial  reference  to  its 
mode  of  onset,  its  probable  duration,  to  the  noticeable  symptoms, 
and  to  previous  treatment. 


Fig.  27. 


Tracings  of  the  spine  illustrating  the  recession  of  deformity. 

3.  The  physical  examination.  This  should  include  the  general 
condition  of  the  patient,  the  height  and  weight,  the  attitude,  the 
character  of  the  disease,  whether  progressive,  as  indicated  by 
muscular  spasm  and  pain  on  motion,  or  quiescent,  the  presence 
of  abscess  or  paralysis  as  a  complication,  and,  finally,  the  position 
and  extent  of  the  disease.  This  is  best  shown  by  a  tracing,  made 
by  means  of  a  strip  of  lead  or  pure  tin,  of  such  thickness  that  it 
may  be  readily  moulded  on  the  spine  and  yet  hold  its  shape  when 
removed  (Fig.  27). 

The  tracing  should  be  of  the  entire  spine,  made  while  the 
patient  lies  extended  in  the  prone  position,  and  the  exact  location 
of  the  most  prominent  spinous  processes  should  be  marked  upon 
it.  In  determining  the  position  of  the  disease  it  is  well  to  count 
the  spinous  processes  from  below  upward,  beginning  with  that 
of  the  fourth  lumbar  vertebra,  which  lies  on  a  line  drawn  between 
the  highest  points  of  the  iliac  crests.     There  are  other  landmarks 

5 


QQ  ORTHOPEDIC  S UB GEB  Y. 

that  are  approximately  correct.  Sometimes  the  last  rib  may  be 
traced  to  its  origin ;  the  scapula  covers  the  second  and  seventh 
ribs,  the  root  of  the  spine  of  the  scapula  and  the  middle  point  of 
the  glenoid  cavity  being  on  a  line  with  the  third,  and  its  inferior 
angle  opposite  the  tip  of  the  seventh  dorsal  spinous  process.  The 
upper  margin  of  the  sternum  is  opposite  the  interval  between 
the  second  and  third  dorsal  vertebrae.  In  many  instances  the 
vertebra  prominens  and  the  spinous  process  of  the  axis  can  be 
identified.  Such  landmarks  are,  of  course,  somewhat  displaced  if 
the  deformity  is  extreme,  but  they  are  always  sufficiently  correct 
to  check  errors  in  counting  the  spinous  processes. 

The  history  furnishes  a  foundation  on  which  treatment  is  con- 
ducted and  from  which  its  results  may  be  determined.  The 
study  of  final  results  has  become  of  great  importance  in  ortho- 
pedic surgery,  and  on  this  account  the  record  should  present  the 
condition  of  the  patient  when  treatment  is  begun,  in  a  form  that 
may  be  readily  understood,  not  only  ])y  its  writer  when  details 
have  been  forgotten,  but  by  anyone  who  may  in  after  years  con- 
sult it.  In  this  history  the  complications  and  incidents  and  the 
changes  in  the  treatment  should  be  noted  at  regular  inter\^als 
until  the  patient  is  cured. 

Treatment.  The  general  treatment  of  tuberculous  disease  is 
considered  in  Chapter  V.  Pott's  disease  is  the  most  important 
of  the  tuberculous  affections  of  the  bones,  and  the  importance  of 
proper  surroundings,  proper  food,  sunlight,  and  above  all  open 
air  Ijoth  day  and  night,  if  possible,  can  hardly  be  exaggerated. 

The  General  Principles  of  Mechanical  Treatment.  Under  normal 
conditions  the  weight  of  the  head  and  of  the  thoracic  and  abdom- 
inal organs  tends  to  bend  the  spine  forward  and  downward — a 
tendency  that  is  resisted  by  the  action  of  the  muscles  of  the  back. 
If  the  resistance  is  weakened,  as  in  Pott's  disease  by  the  direct 
destruction  of  the  weight-bearing  portion  of  the  spine,  this  ten- 
dency toward  deformity  is,  of  course,  greatly  increased.  Thus, 
the  pressure  of  the  superincumbent  weight  upon  the  weakened 
part  and  the  strain  of  motion  are,  from  the  mechanical  stand- 
point, the  most  important  factors  in  the  production  of  deformity. 

When  the  body  is  bent  forward,  as  in  the  stooping  posture, 
the  intervertebral  discs  are  compressed  and  the  pressure  upon  the 
vertebral  bodies  is  increased.  When  the  body  is  held  erect  or  is 
bent  backward  this  pressure  is  lessened,  and  a  part  of  the  weight 
is  transferred  to  the  articular  processes  and  to  the  posterior  parts 
of  the  column.     The  object  of  a  brace  or  other  support  is  to  hold 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  67 

the  spine  in  this  extended  position,  so  that  pressure  on  the  dis- 
eased vertebrae  may  be  removed.  One  aims  to  splint  the  diseased 
spine  as  effectively  as  if  it  were  broken,  in  order  to  relieve  the 
discomfort  and  pain,  so  depressing  to  the  patient,  and  to  secure 
the  rest  that  is  essential  to  repair. 

The  effectiveness  of  a  particular  splint  or  support,  whether 
applied  to  a  broken  bone  or  to  a  diseased  spine,  depends  upon  the 
area  that  it  covers  on  either  side  of  the  part  to  be  supported,  and 
upon  the  accuracy  of  its  adjustment,  as  well  as  upon  the  damage 
that  the  part  has  already  sustained,  and  the  strain  to  which  it 
still  may  be  subjected. 

From  this  standpoint  it  is  evident  that  it  is  difficult  to  apply 
effective  support  to  the  trunk  because  of  its  size,  shape,  and  con- 
tents, and  it  is  apparent  also  that  the  mechanical  conditions  are 
more  favorable  in  some  parts  than  in  others.  For  example,  the 
splint  is  likely  to  be  effective  w^hen  the  disease  is  of  the  lower 
dorsal  region,  because  its  two  extremities,  attached  to  the  pelvis 
and  to  the  shoulders,  are  equidistant  from  the  point  to  be  sup- 
ported. These  conditions  are  reversed  in  disease  of  the  upper 
thoracic  region,  because  the  weight  of  the  head  and  of  the  arms 
tends  to  increase  the  deformity,  and  because  of  the  insufficient 
leverage  that  can  be  secured  for  the  supporting  appliance.  The 
pelvis  is  the  base  of  support  for  all  forms  of  splints,  and  if  it  be 
smaller  than  the  abdomen,  as  in  infancy,  the  adjustment  of  effi- 
cient support  is  more  difficult  than  in  older  subjects. 

In  actual  practice  the  treatment  of  Pott's  disease  is  inhuenced 
by  the  age  of  the  patient,  the  situation  of  the  disease,  the  dura- 
tion of  the  deformity,  and  by  many  other  circumstances,  but  the 
relative  efficiency  of  braces  or  other  appliances  may  be  decided 
on  purely  mechanical  grounds.  Thus,  as  the  ultimate  deformity 
of  Pott's  disease  is,  in  great  degree,  caused  by  the /orce  of  gravity 
acting  on  a  v^eakened  spine,  the  most  effective  treatment  must  be 
fixation  in  the  horizontal  position,  for  in  this  position  the  strain 
of  use  and  the  pressure  of  superincumbent  weight  can  be  removed 
completely ;  and  relief  from  jars  and  strains  that  favor  the  exten- 
sion of  the  disease  can  be  assured. 

Horizontal  Fixation.  Apparatus  for  this  treatment  must  be 
quite  independent  of  the  bed  on  which  it  may  be  placed,  and  of 
such  appliances  several  forms  may  be  employed. 

The  reclinationgypsbettes  of  Lorenz^  is  simply  a  posterior  case 
of  plaster-of-Paris  enclosing  the  head  and  body. 

1  HoflTa.    Lehrbuch  der  Orthopiidischen  Chir.,  3d  ed.,  p.  324. 


68 


ORTHOPEDIC  SUBOEBY. 


The  Phelps  bed  is  somewhat  similar.  A  thin  board  is  cut  iu 
the  outline  of  the  child's  bodv  and  extended  legs.  It  is  padded 
with  wadding  and  covered  with  cotton  cloth  ;  the  patient  is  then 
placed  upon  it,  and  plaster  bandages  are  applied  to  enclose  the 
body  and  the  legs.  The  front  is  then  cut  away,  so  that  the 
patient  may  be  removed  from  the  bed  for  an  occasional  bath  and 
change  of  clothing.^ 

Fig.  28. 


Bradford's  bed-frame.    (Bradford  aud  Lovett.) 

The  wire  cuirasse  has  been  popularized  by  Sayre  f  it  is  an 
effective  appliance,  although  somewhat  cumbersome  and  expen- 
sive. 

An  effective  and  convenient  form  of  support  is  the  Bradford 
frame  or  stretcher.  This  is  a  rectangular  frame  a  few  inches 
longer  and  slightly  wider  than  the  patient's  body.  Over  the 
frame  covers  of  strong  canvas  are  drawn  tightly  by  means  of 

Fig.  29. 


The  modified  frame  with  the  bandage. 

corset  lacings  or  straps  on  its  under  surface,  leaving  an  interval 
beneath  the  buttocks  for  the  use  of  the  bed  pan  (Fig.  28). 

The  efficiency  of  this  appliance  may  be  increased  by  changing 
it  in  several  particulars,  and  the  following  description  applies  to 
the  apparatus  used  by  the  writer  : 

The  stretcher  frame  is  made  of  ordinary  galvanized  gas-pipe 
or  of  steel  tubing  of  a  smaller  diameter.     It  should  be  about  four 

1  The  Phelps  Plaster-of-Paris  Bed.    Trans.  Amer.  Ortho.  Assoc,  1891,  vol.  iv.  p.  83. 
-  La  gouttiere  de  Bonnet.    R6dard,  Chir.  Orthopedique,  p.  243. 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


69 


inches  longer  than  the  child  and  about  four-fifths  as  wide,  the 
lateral  bars  corresponding  to  the  articulating  surfaces  of  the  four 
extremities  with  the  trunk.  The  ordinary  dimensions  are  seven 
and  one-half  by  thirty-eight  inches,  or  the  width  to  length  about 
as  one  to  five. 

At  first  thought  it  would  seem  that  the  side  bars  might  cause 
uncomfortable  pressure  on  the  overhanging  shoulders,  but  as  the 

Fig.  30. 


The  stretcher  frame,  showing  the  canvas  cover  and  apron. 

arms  are  set  upon  the  middle  of  the  lateral  aspect  of  the  trunk 
and  thus  on  a  considerably  higher  plane  than  the  dorsum,  there 
is  but  bare  contact  when  the  cover  is  fairly  rigid.  Before  apply- 
ing the  cover  one  may  with  advantage  wind  bandages  tightly 
about  the  frame  at  the  point  which  is  to  support  the  trunk  in  order 
to  make  the  support  as  unyielding  as  possible  (Fig.  29).     The 

Fig.  31. 


The  frame  bent  to  assure  overextension  of  the  spine.    The  recession  of  deformity  obtained 
in  this  case  is  shown  by  the  tracings,  Fig.  27. 


cover  should  be  of  strong  canvas  suitably  protected  in  the  centre 
by  rubber  cloth.  This  is  applied  and  is  drawn  tight  by  means 
of  corset  lacings  and  straps.  Upon  this  two  thick  pads  of  felt 
are  sewed ;  these  should  be  about  seven  inches  in  length  and 
about  three-quarters  of  an  inch  in  thickness,  so  placed  as  to  pass 
on  either  side  of  the  spinous  processes  at  the  seat  of  the  disease, 
thus  protecting  them  from  pressure,  fixing  the  part  more  firmly. 


70 


ORTHOPEDIC  SURGERY. 


and  increasing  the  leverage  of  the  apparatus.  The  child,  wearing 
only  an  undershirt,  stockings,  and  diaper,  is  placed  upon  the 
frame  and  is  fixed  there  usually  by  a  front  piece  or  apron  similar 
to  that  used  with  the  spinal  brace.  As  soon  as  the  patient  has 
become  accustomed  to  the  restraint,  one  begins  to  overextend  the 
spine  by  bending  the  bars  from  time  to  time  upward  beneath  the 
kyphosis  with  the  aim,  as  has  been  stated,  of  actually  separating 
the  diseased  vertebral  bodies  and  obliterating  all  the  physio- 
logical curves  of  the  spine,  so  that  the  body  shall  be  finally  bent 
backward  to  form  the  segment  of  a  circle.  The  greatest  con- 
vexity is  at  the  seat  of  the  disease,  and  as  the  head  and  lower 
extremities  are  on  a  much  lower  level,  an  element  of  gravity 
traction  is  present  in  some  instances,  while  the  support  of  the 
spine,  as  a  whole,  is  much  more  comprehensive  than  when  the  body 

Fig.  32. 


The  modified  stretcher  frame,  showing  overextension  of  the  spine,  with  traction  for  the 
head  and  limbs  as  applied  for  Pott's  paraplegia.  Caused  by  disease  in  the  upper  dorsal 
region.    (See  Fig.  53.) 


lies  upon  a  plane  surface  (Fig.  31).  The  gradual  overextension  of 
the  spine  by  bending  the  frame  in  this  manner  is  so  definite  and 
simple  that  it  may  be  easily  carried  out  by  the  physician,  and  it 
may  be  exaggerated  slightly  to  compensate  for  the  sagging  of  the 
cover.  Thus,  it  is  far  more  effective  than  any  form  of  padding 
or  other  form  of  support  with  which  I  am  familiar.  Upon  this 
frame  the  child  lies  constantly,  its  clothing  being  made  suffi- 
ciently large  to  inckide  the  apparatus,  thus  assuring  additional 
fixation.  Once  a  day  in  most  instances  the  child  is  removed 
from  the  frame  and  is  carefully  turned  face  downward  upon 
a  large  pillow  ;  the  back  is  then  inspected,  bathed  with  alcohol 
and  powdered,  and  the  apparatus  is  then  reapplied.  It  is,  of 
course,  desirable  to  have  two  equipped  frames,  but  this  is  by  no 
means  essential. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  71 

The  effect  of  the  continued  fixation  upon  the  back  is  not 
merely  to  change  the  contour  of  the  spine,  but  of  the  entire  trunk 
as  well ;  to  flatten  and  broaden  the  body.  This  increase  of  the 
lateral  at  the  expense  of  the  anteroposterior  diameter  is  quite  the 
reverse  of  the  natural  tendency  of  the  deformity,  and  it  is,  there- 
fore, a  favorable  rather  than  an  unfavorable  effect  of  the  treat- 
ment. The  same  tendency  in  the  lower  region  may  be  checked 
by  the  use  of  a  flannel  binder,  such  as  is  ordinarily  worn  by 
infants. 

Fig.  33. 


A  perfect  cure  obtained  by  the  stretcher  treatment.    The  situation  of  the  disease  is  shown 
in  the  X-ray  picture,  Fig.  34. 

The  method  of  attaching  the  patient  to  the  frame  varies  some- 
what according  to  the  situation  and  character  of  the  disease.  In 
ordinary  cases,  as  has  been  stated,  a  canvas  apron,  similar  to  that 
used  with  the  back  brace  (Fig.  41),  is  applied,  and  is  buckled  to 
the  .sides  of  the  frame.  If  advisable  the  shoulders  may  be  held 
down  Ijy  straps  crossing  the  chest,  or  by  axillary  straps  connected 
by  a  chest  band.  If  still  more  effective  fixation  is  desired,  as  in 
disease  of  the  upper  dorsal  region,  the  anterior  shoulder  brace,  as 
used  with  the  back  brace  (Fig.  30),  may  be  attached  to  the  axil- 


72 


ORTHOPEDIC  SURGERY. 


lary  straps.     In  disease  of  the  upper  and  middle  regions  of  the 
spine  restraint  of  the  legs  is  not  necessarj^,  but  in  lumbar  disease 


Fig.  34. 


An  X-ray  picture  of  the  case  (Pig.  33)  before  treatment.  The  situation  of  the  disease  at  the 
junction  of  the  first  and  second  lumbar  vertebrse  is  indicated  by  the  lateral  deviation,  and 
by  the  approximation  of  the  dotted  lines  1  and  2  as  compared  to  the  others. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  73 

a  broad  swathe  should  be  passed  across  the  thighs,  and  if  psoas 
spasm  is  present  traction  may  be  employed. 

In  disease  of  the  upper  region  of  the  spine  a  certain  amount  of 
traction  is  desirable  to  aid  in  the  reduction  of  deformity  and  to 
prevent  the  patient  from  raising  the  head.  This  traction  is 
usually  applied  by  means  of  the  halter  as  used  with  the  jury 
mast.  The  straps  are  attached  to  a  crossbar  at  the  upper  extrem- 
ity of  the  frame,  and  traction  may  be  made  by  simply  tightening 
them,  or  if  the  upper  part  of  the  frame  is  somewhat  elevated  the 
weight  of  the  patient's  body  makes  the  proper  extension.  This 
position  has  the  advantage,  also,  of  allowing  the  patient  a  better 
opportunity  to  see  what  is  going  on  about  him  (Fig.  32). 

In  disease  of  the  middle  cervical  region  traction  is  usually  of 
service,  and  fixation  of  the  head  is  always  indicated  in  addition 
when  the  occipito-axoid  region  is  involved,  either  by  sand  bags 
on  either  side,  or,  preferably,  by  some  form  of  metal  brace. 

Greater  fixation  of  the  spine  may  be  desirable  in  cases  of  more 
acute  disease.  This  may  be  attained  by  the  use  of  a  light  back 
brace,  or  a  plaster  jacket,  in  connection  with  the  frame.  Such 
support  should  not  be  applied,  however,  until  the  recession  of 
deformity,  which  is  to  be  expected  under  treatment  by  the  hori- 
zontal fixation  and  overextension,  has  been  obtained  (Fig.  27). 

As  this  frame  is  simply  a  horizontal  brace  the  child  may 
spend  as  much  time  in  the  open  air  as  would  be  practicable  were 
any  other  appliance  used. 

Personally,  I  have  never  seen  other  than  favorable  results  from 
this  method  of  treatment.  Pain  and  discomfort  are,  as  a  rule, 
relieved  almost  immediately,  and  there  is  a  corresponding  im- 
provement in  the  general  condition  of  the  patient.  Meanwhile 
the  growth  of  the  trunk,  which  is  so  often  checked  by  the  dis- 
ease and  by  the  deformity,  appears  to  progress  with  normal 
rapidity,  so  that  the  apparatus  may  be  actually  outgrown  before 
the  termination  of  this  part  of  the  treatment.  Horizontal  fixa- 
tion is,  of  course,  a  treatment  not  complete  in  itself,  since  it  must 
be  supplemented  by  the  usual  supports  when  the  erect  attitude  is 
again  assumed.  Its  duration  varies  from  six  to  eighteen  months. 
The  indications  for  its  discontinuance  are  the  correction  of  deform- 
ity, the  apparent  quiescence  or  cure  of  the  local  disease  as  indi- 
cated by  the  physical  signs,  and  by  the  behavior  of  the  patient, 
who,  as  repair  advances,  becomes  restless  when  removed  from  the 
frame,  evidently  desiring  to  sit  and  to  stand. 

At  this  stage  it  is  well  to  apply  the  ambulatory  support  some 


74 


ORTHOPEDIC  SURGERY. 


time  before  the  patient  is  released  from  the  frame,  allowing  little 
by  little  the  changes  in  attitude  and  habits.  If  the  plaster  jacket 
is  to  be  used  it  may  be  applied  during  longitudinal  suspension  or 
otherwise,  after  which  the  child  is  immediately  replaced  upon  the 
frame,  where  the  plaster  is  allowed  to  harden ;  thus  it  holds  the 
spine  in  an  attitude  to  which  it  has  become  accustomed.  (Fig.  58.) 
Ambulatory  Supports.  The  two  types  of  ambulatory  sup- 
ports are  the  steel  brace  and  the  plaster  jacket. 


Fig.  35. 


The  Taylor  brace  and  head  support  applied  for  disease  of  the  upper  dorsal  region. 


The  Back  Brace.  The  spinal  brace,  or  spinal  assistant,  as  the 
original  appliance  of  Dr.  C.  F.  Taylor  was  called,  consists  essen- 
tially of  two  steel  bars  that  are  applied  on  either  side  of  the 
spinous  processes  from  the  top  to  the  bottom  of  the  spine.  At 
the  seat  of  the  disease  pads  are  placed  to  provide  for  greater 
pressure  and  fixation,  and  to  form  a  fulcrum  over  which  the 
spine  may  be  straightened  or  held  erect,  when  the  two  extremities 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


75 


of  the  brace  are  firmly  attached  to  the  pelvis  and  to  the  shoulders. 
The  attachment  at  the  lower  end  is  made  by  means  of  a  pelvic 
band  of  sheet  steel  (gauge  18)  from  one  and  a  half  to  two  inches 
in  width,  long  enough  to  reach  from  one  iliac  spine  to  the  other ; 
it  is  placed  as  low  as  possible  on  the  pelvis ;  in  other  words,  just 
above  the  upper  extremities  of  the  trochanters.  To  this  the 
uprights  are  firmly  attached  at  an  interval  of  from  one  and  a 
quarter  to  one  and  three-quarter  inches  from  one  another,  so  that 
the  spinous  processes  may  pass  between  them,  while  pressure  is 
made  on  the  lateral  masses  of  the  vertebrse.  The  uprights  are 
made  of  varying  strength,  according  to  the  age  of  the  patient, 
usually  about  one-half  an  inch  in  width  (of  gauge  8  to  12)  and  of 
such  quality  of  steel  that,  although  unyielding  to  the  strain  of  use, 
it  may  be  readily  bent  by  wrenches,  and  thus  accurately  adjusted 
to  the  back.  The  uprights  reach  to  the  root  of  the  neck,  or  to 
about  the  level  of  the  second  dorsal  vertebra;  from  this  point 
two  short  arms  of  metal  project  forward  and  outward  on  either 
side  of  the  neck,  reaching  to  about  the  middle  of  the  clavicles. 

To  these  padded  shoulder  straps  are 
attached,  which  pass  through  the 
axillae  to  a  crossbar  on  the  back 
brace ;  thus,  downward  pressure 
on  the  shoulders  is  avoided  and 
increased  leverage  is  assured  (Fig. 
35). 

Opposite  the  area  of  disease  two 
strips  of  thin  steel  about  three  inches 
in  length  are  fixed ;  these  are  slightly 
wider   than    the   uprights   and  are 


Fig.  37. 


The  Taylor  back  brace.    {H.  L.  Taylor.) 


The  Taylor  chest  piece.    Two  triangular  pads 
of  hard  rubber  connected  by  a  bar. 


76 


ORTHOPEDIC  SUEGEBY. 


perforated  for  the  attachment  of  the  pressure  pads.  These  may- 
be made  of  layers  of  canton  flannel  or  felt,  or  unyielding  mate- 
rial, such  as  leather  or  hard  rubber,  may  be  used  instead.  The 
pads  should  project  from  a  quarter  to  a  half-inch  in  front  of  the 
uprights  in  order  that  firm  and  constant  pressure,  to  the  extent 
that  the  skin  will  tolerate,  may  be  made  at  the  seat  of  disease 
(Fig.  36). 

In  measuring  for  this  brace  the  patient  is  placed  in  the  prone 
posture  and  a  tracing  of  the  outline  of  the  back  is  made  by  means 


Fig.  38. 


Fig.  39. 


Backward  traction  on  the  shoulders  fixes 
the  upper  dorsal  region. 


The  anterior  shoulder  brace  and  its 
attachment. 


of  the  lead  tape.  This  outline  may  be  cut  in  cardboard  and  fitted 
to  the  back ;  in  fact,  if  the  mechanic  is  unfamiliar  with  the  work, 
each  part  of  the  brace,  uprights,  pelvic  band,  etc.,  may  be  cut  in 
cardboard  and  attached  to  one  another  to  serve  as  a  model. 
Before  the  brace  is  finished  it  should  be  applied  to  the  back  and 
should  be  adjusted  carefully  by  means  of  wrenches.  The  pelvic 
band  and  tbe  parts  that  come  in  direct  contact  with  the  skin  are 
usually  covered  with  leather,  or,  in  the  treatment  of  young  chil- 
dren, with  rubber  plaster  and  canton  flannel  to  prevent  rusting. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  77 

If  the  brace  is  applied  before  the  stage  of  deformity  it  should 
follow  the  exact  shape  of  the  spine,  but  if  deformity  is  present, 
particularly  in  disease  of  the  thoracic  region,  it  should  be  made 
somewhat  straighter,  in  order  to  permit  a  gradual  correction  of 
the  compensatory  lordosis  in  the  lumbar  region,  and  for  increased 
leverage  above  the  deformity.  As  has  been  stated,  a  certain 
amount  of  recession  of  deformity  can  be  obtained  by  rest  in  the 
horizontal  position,  and  if  practicable  this  improved  contour 
should  be  attained  before  the  brace  is  applied.  The  apparatus  is 
held  in  place  by  an  "  apron  "  (Fig.  41),  which  covers  the  chest 
and  abdomen,  to  which  straps  are  attached.  Ordinarily  this  is 
made  of  strong  linen  or  cotton  cloth,  but  a  canvas  front  shaped 
accurately  to  the  body  and  strengthened  with  whalebone,  is  a 
more  comfortable  and  efficient  support.  In  applying  the  brace 
the  pelvic  band  is  first  attached  to  the  apron,  then  the  straps  in 
order,  from  below  upward,  and,  finally,  the  shoulder  straps. 
Each  strap  is  tightened  until  the  brace  is  firmly  fixed  in  proper 
position.  When  a  brace  is  properly  applied  and  properly  fitted 
it  holds  its  place  by  friction,  but  when  the  disease  is  of  the 
lower  lumbar  region,  or  if  the  brace  has  a  tendency  to  upward 
displacement  perineal  straps  should  be  used  to  hold  the  pelvic 
band  firmly  in  its  place  (Fig.  36).  At  first  the  brace  is  removed 
once  a  day  in  order  to  wash  and  powder  the  back,  the  same  care 
being  observed  in  moving  the  child  as  in  the  treatment  by  the 
frame ;  but  when  the  skin  has  become  accustomed  to  the  pressure 
the  brace  should  be  removed  only  at  infrequent  intervals,  and 
thus,  if  desirable,  only  under  the  supervision  of  the  surgeon. 

This  description  indicates  the  essential  qualities  of  the  back 
brace.  It  has  been  modified  in  various  ways ;  for  example.  Dr. 
Taylor  long  since  discarded  the  straight  pelvic  band  in  favor  of 
one  of  a  U-shape  (Fig.  36).  This  makes  the  brace  somewhat 
lighter  and  relieves  the  sacrum  from  pressure,  but  it  does  not  add 
to  its  effectiveness.  The  efficiency  may  be  increased,  however,  by 
improving  the  attachment  at  its  upper  extremity,  as  is  illustrated 
in  Fig.  37,  in  which  two  triangular  pads  of  hard  rubber  connected 
by  a  metal  bar  are  employed. 

This  is  an  improvement  on  the  simple  shoulder  straps  of  the 
original  brace,  but  it  does  not  provide  the  quality  of  support  and 
fixation  that  is  desirable  when  the  disease  is  of  the  upper  or 
middle  segment  of  the  thoracic  region.  In  such  cases  the  upper 
part  of  the  cliest  is  flattened,  the  inclination  of  the  ribs  is  in- 
creased, and  the  shoulders  droop  forward,  carrying  with  them  the 


78 


ORTHOPEDIC  SURGERY. 


scapulae.      Thus,  the  weight  and  the  strain  of  the  motion  and  use 
of  the  arms  tend  to  increase  the  deformity. 

In  health  direct  forward  or  reaching  movements  of  the  arms 
are  always  accompanied  by  an  increase  in  the  posterior  curvature 
of  the  dorsal  spine.  On  the  other  hand,  if  the  shoulders  are 
drawn  backward  and  held  in  this  attitude,  the  curvature  of  the 
spine  is  lessened  and  the  chest  is  elevated  and  expanded  (Fig.  38). 


Fig.  40. 


The  Taylor  back  brace  and  head  support  combined  with  the  Whitman  anterior  support. 


In  the  treatment  of  disease  of  the  upper  dorsal  region  it  should 
be  the  aim,  in  the  application  of  a  brace,  to  follow  this  indi- 
cation and  to  apply  pressure  directly  upon  the  extremities  of  the 
shoulders  to  assure  the  greatest  possible  fixation  of  the  spine  and 
to  restrain  the  movements  of  the  arms  that  tend  to  increase  the 
deformity. 

The  accompanying  diagrams  (Fig.  39)  show  how  such  support 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


79 


may  be  applied.  Two  saucer-shaped  plates  of  hard  rubber  or 
padded  metal  (Fig.  40)  cover  the  heads  of  the  humeri  and  are  joined 
by  a  rigid  bar  of  steel,  which  passes  across  but  does  not  touch  the 
chest.  On  the  back  brace  are  placed  two  triangular  pads  of 
similar  construction  which  cover  and  press  upon  the  scapulae. 
These  pads  are,  however,  not  essential  and  are  often  omitted. 
The  back  brace  is  applied,  the  shoulders  are  then  drawn  back- 
ward and  the  shoulder-cups  are  firmly  attached  by  straps  to  the 
neck  bars  of  the  brace  above,  and  by  axillary  bands  below  in  the 
usual  manner.     By  this  means  the  thorax  is  elevated  and  the 


Fig.  41. 


Fig.  42. 


The  anterior  shoulder  brace. 


The  scapular  pads. 


spine  is  more  effectively  fixed,  while  direct  movement  of  the  arms 
forward  is  made  impossible.  It  would  seem  that  such  restraint 
would  be  irksome  to  the  patient,  but  in  an  extended  use  of  the 
apparatus  this  has  never  caused  complaint.  In  many  instances, 
even  when  the  disease  is  as  low  as  the  tenth  dorsal  vertebra,  it 
may  be  used  with  advantage,  but  it  is  especially  indicated  when 
the  disease  is  in  the  neighborhood  of  the  seventh  dorsal  vertebra. 
In  connection  with  the  shoulder  brace  it  is  usually  advisable  to 
apply  a  support  beneath  the  chin  to  prevent  the  forward  inclina- 
tion of  the  neck  and  to  tilt  the  head  somewhat  backward.     A 


80 


OR  THOPEDIG  S  UR  GER  Y. 


very  simple  and  iaoffensive  support  of  this  character  is  a  loop  of 
steel  surrounding  the  neck  and  attached  by  screws  to  a  back  bar 
on  the  brace  (Fig.  43).  If  a  more  efficient  brace  is  required,  as 
when  the  disease  is  of  the  upper  dorsal  or  cervical  regions,  the 
Taylor  head  support  should  be  used.  This  is  an  oval  ring  of 
steel  which  may  be  clasped  about  the  neck  by  means  of  a  lateral 
hinge.  On  the  front  a  cup  of  hard  rubber  supports  the  chin  and 
behind  the  ring  fits  upon  an  upright  pivot  that  may  be  raised  or 
lowered  upon  a  crossbar  on  the  upper  part  of  the  brace;  free 
lateral  motion  is  allowed,  or  it  may  be  checked  by  means  of  a 
screw  (Fig.  45). 

If  absolute  fixation  of  the  head  is  indicated,  as  in  disease  at  or 
near  the  occipito-axoid  region,  two  steel  uprights  may  be  attached  to 
the  back  of  the  ring  ;  these  are  bent  to  fit  the  posterior  and  lateral 
aspect  of  the  head  closely, 
and  a  band  of  webbing  is 
passed  from  one  upright 
to  the  other  and  about 
the  forehead. 

In  applying  the  sup- 
port the  chin  should  al- 
ways be  tilted  slightly 
upward  in  order  to  throw 

Fig.  43. 


Fig.  44. 


The  loop  head  support. 


Disease  of  the  middle  cervical  region,  showing 
the  deformity  and  attitude.  This  patient  had  been 
paralyzed  for  one  year  before  treatment  was  begun 

(See  Fig.  45.) 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


81 


the  weight  of  the  head  backward  (Fig.  45).  The  adjustment  of 
the  head  support  is  made  easier  if  the  pivot  is  attached  to  the 
upright  by  means  of  a  ball  and  socket  joint  (Shaffer)  (Fig.  35) 
that  may  be  regulated  by  a  screw  and  key ;  this  arrangement  is 
of  service  when  the  head  is    distorted,  but  it  is    by  no    means 


necessary. 


Fig.  46. 


The  Taylor  brace  and  head  support  applied 
to  the  patient  shown  in  Fig.  44. 


The  Taylor  brace  with  jury  mast. 


When  the  Taylor  head  support  or  similar  appliances  are  used 
the  greater  part  of  the  pressure  is  sustained  by  the  chin,  which 
may,  after  a  time,  undergo  an  unsightly  recession.  It  may  be  of 
advantage,  therefore,  in  such  cases,  and  particularly  when  restraint 
of  the  motion  of  the  neck  is  desirable  to  transfer  this  pressure  to 

6 


82  OB THOPEDIC  S  UB GEB  Y. 

the  forehead  and  occiput  by  extending  the  back  bars  upward 
over  the  back  of  the  head,  as  in  Fig.  51. 

A  jury  mast  may  be  used  to  support  the  head  also;  its  adjust- 
ment will  be  described  in  connection  with  the  plaster  jacket,  with 
which  it  is  usually  associated  (Fig.  46). 

The  Plaster  Jacket.  It  was  claimed  at  one  time  that  a  plaster 
jacket  applied  while  the  body  was  partially  suspended  would 
actually  relieve  the  weakened  area  of  superincumbent  weight  by 
holding  the  diseased  surfaces  apart.  This  is  not  the  fact.  The 
jacket  supports  the  spine  as  does  the  brace  by  holding  it  in  the 
erect  or  extended  position.  One  is  a  circular  and  the  other  is  a 
posterior  splint.  There  is  this  difference,  however :  the  brace  fits 
the  spine  accurately  and  holds  its  place  by  pressure  and  friction  ; 
the  jacket  is  held  in  place  by  the  support  of  the  projecting  pelvic 
bones;  it  lacks  the  accuracy  of  adjustment  of  the  brace  at  the 
seat  of  disease,  but,  on  the  other  hand,  it  provides  a  solid  support 
on  the  front  and  sides  of  the  body. 

Each  appliance  has  advantages  and  disadvantages  that  become 
apparent  in  the  treatment  of  certain  phases  of  the  disease  or  con- 
ditions of  the  patient. 

The  plaster  bandage  is  a  simple  support,  whose  efficiency 
depends  upon  the  accuracy  of  its  adjustment  to  the  irregularities 
of  the  body,  and  upon  the  leverage  that  it  exerts  above  and  below 
the  weakened  part.  It  should  be  applied  while  the  body  is  held 
in  the  best  possible  position ;  its  inner  surface  should  be  smooth, 
and  the  bony  prominences  that  are  susceptible  to  friction  and 
pressure  should  be  protected. 

A  seamless  shirt  should  be  worn  ;  these  are  made  iu  several 
sizes  and  are  sold  l)y  the  yard  at  a  low  price.  The  shirt  should 
fit  the  body  closely,  and  should  be  long  enough  to  reach  to  the 
knees.  On  the  front  and  back  bands  of  linen  or  China  silk  or 
other  material,  about  three  inches  in  width  and  three  feet  iu 
length,  should  be  placed  beneath  the  shirt.  These  bands,  or, 
as  Lorenz  calls  them,  "  scratchers,"  are  for  the  purpose  of 
keeping  the  skin  clean.  The  patient  is  then  placed  upon  a 
stool,  and  the  halter  of  the  suspension  apparatus  is  carefully 
adjusted ;  the  arms  are  extended  over  the  head  and  the  hands 
clasp  the  straps  or  rings ;  thus,  the  chest  is  expanded  to  its  full 
limit.  Sufficient  tension  is  made  upon  the  rope  to  partially 
suspend  the  body  and  to  draw  the  spine  into  the  best  possible 
attitude ;  in  most  instances  the  heels  should  be  slightly  lifted 
from  the  stool. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  83 

Dr.  Sayre,  to  whom  we  are  indebted  for  the  exposition  of  this 
valuable  means  of  treatment,  insisted  that  the  sensations  of  the 
patient  should  be  the  guide,  and  that  traction  should  be  made 
only  to  the  point  of  comfort.  This  is  a  valuable  indication  in 
the  treatment  of  the  adult,  but  it  is  not  often  of  service  in  child- 
hood. 

Before  applying  the  plaster  bandage  pieces  of  piano  felting  or 
canton  flannel  of  sufficient  thickness  are  placed  about  the  anterior 
pelvic  spines,  over  the  upper  part  of  the  sternum,  and  a  thin 
strip  is  sometimes  used  to  cover  the  spinous  processes.  Finally, 
long  strips  of  saddlers'  felt,  or  of  other  material  of  sufficient 
thickness,  are  applied  on  either  side  of  the  prominent  spinous 
processes  to  protect  them  from  friction  and  to  provide  greater 
pressure  and  fixation  at  the  seat  of  disease.  In  the  treatment  of 
adolescent  or  adult  females  the  breasts  should  be  covered  with  a 
layer  of  cotton,  which  may  be  removed  later  if  necessary,  to  pre- 
vent pressure.  The  ' '  dinner  pad  "  is  now  not  often  used,  except  in 
the  treatment  of  adults  and  in  certain  cases  in  which  the  abdomen 
is  retracted.  In  childhood  the  abdomen  is  usually  prominent, 
and  in  most  instances  no  extra  space  is  required.  Occasionally, 
however,  one  is  told  that  the  patient  complains  of  discomfort 
after  meals,  evidently  due  to  constriction,  and  in  such  cases  proper 
allowance  must  be  made.  The  pad,  which  is  supposed  to  repre- 
sent the  space  necessary  after  a  full  meal,  is  made  by  folding  a 
small  towel  into  the  shape  of  a  sandwich ;  this  is  attached  to  a 
bandage  and  is  placed  beneath  the  shirt  just  below  the  ensiform 
cartilage;  when  the  jacket  is  completed  it  may  be  drawn  out 
by  means  of  the  hanging  bandage,  leaving  the  additional  space 
for  emergencies. 

The  materials  for  the  jacket  should  be  of  the  best.  Fresh 
dental  plaster  should  be  rubbed  by  hand  into  strips  of  crinoline, 
free  from  glue.  The  bandages  should  be  from  three  to  five 
inches  in  width  and  six  yards  in  length,  from  three  to  six  being 
required  for  a  jacket,  according  to  the  size  of  the  child.  They 
should  be  placed  on  end,  in  a  pail  of  warm  water,  one  at  a  time 
as  they  are  used.  No  salt  or  alum  should  be  used  to  hasten  the 
setting  of  the  plaster;  in  fact,  if  such  aid  is  necessary,  it  is  unfit 
for  use.  AVhen  the  bubbles  have  ceased  to  rise  the  bandage  is 
squeezed  gently  until  no  water  drips  from  it,  and  the  loose  threads 
are  removed  from  the  ends. 

One  person  should  sit  behind  the  patient  and  one  in  front, 
while  a  third  may  hold  the  rope  and  check  the  swaying  of  the 


84  OBTHOPEDIC  SUROERY. 

body.  The  one  who  sits  behind  the  patient  may  clasp  the  child's 
legs  between  his  knees  and  thus  assure  better  fixation  of  the 
pelvis.  The  pads  are  held  in  position  until  they  are  fixed  by  the 
plaster  bandages,  which  should  be  applied  with  a  slight  and  even 
tension. 

As  a  rule,  the  jacket  should  be  of  uniform  thickness  through- 
out. This  thickness  need  not  exceed  one-eighth  to  one-fourth  of 
an  inch,  and  it  may  even  be  lighter  in  certain  cases.  It  is  well 
to  make  the  first  turns  about  the  waist,  and  to  use  the  first  band- 
age about  the  pelvis,  since  the  pelvis  is  the  base  of  support ;  and, 
as  the  most  important  point  for  counter-pressure  is  the  chest,  this 
part  should  be  made  especially  strong  and  resistant. 

During  the  application  of  the  jacket  it  should  be  rubbed 
constantly,  in  order  that  the  different  layers  of  bandage  may 
adhere  to  one  another,  and  that  it  may  fit  the  projections  of  the 
pelvis  and  body  closely.  Meanwhile  the  attitude  of  the  patient 
should  be  carefully  watched,  in  order  to  prevent  lateral  inclin- 
ation of  the  body.  In  some  instances  it  is  possible  to  lessen  the 
deformity  by  the  extension  and  by  backward  traction  on  the 
shoulders  and  forward  pressure  on  the  trunk  while  the  jacket  is 
hardening. 

When  the  jacket  is  nearly  firm  it  should  be  trimmed.  In 
many  instances  this  may  be  done  while  the  patient  is  in  the 
swing,  but  if  he  is  fatigued  he  may  be  placed  in  the  recumbent 
posture. 

As  a  rule,  the  front  of  the  jacket  should  reach  from  the  upper 
margin  of  the  sternum  to  the  pubes ;  behind,  from  about  the 
mid-line  of  the  scapulae  to  the  gluteal  fold  ;  laterally,  it  should  be 
cut  away  sufficiently  to  prevent  chafing  of  the  arms ;  and  on 
either  side  of  the  pubes  an  oval  section  is  cut  out,  to  allow  for 
the  flexion  of  the  thighs  in  the  sitting  posture.  Particular  atten- 
tion is  called  to  the  importance  of  making  the  jacket  as  long  as 
possible,  so  that  the  abdomen  may  be  contained  within  it  instead 
of  being  forced  out  beneath  its  lower  border  (Fig.  48).  After 
the  application  of  the  jacket  the  patient  should  remain  in  the 
recumbent  posture  for  at  least  half  an  hour.  A  much  longer 
period  of  recumbency  is  always  advisable,  as  it  does  not  become 
absolutely  firm  for  several  hours.  The  shirt  is  then  drawn  up^ 
over  the  jacket  and  is  sewed  to  the  neck  portion ;  this  adds  much 
to  neatness  and  cleanliness.  The  shirt  must  be  drawn  tightly 
about  the  neck,  in  order  to  guard  the  body  from  the  crumbs  or 
other  objects   that  may  fall  beneath  the  jacket,   and  in  many 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


85 


instances  a  special  protector  in  the  form  of  a  wide  collar  l^ib  may 
be  used  with  advantage. 

The  upper  and  lower  ends  of  the  cleansing  bandages  are  joined 
to  one  another  wath  tape,  and  with  them  the  skin  is  carefully 
rubbed  twice  daily.     When  soiled  they  may  be  replaced. 


Fig.  47. 


Fig.  48. 


The  plaster  jacket,  illustrating  the 
arrangement  of  the  shirt. 


The  plaster  jacket  supporting  the  abdomen. 
The  cleansing  bandages  are  not  shown. 


It  may  be  mentioned  in  this  connection  that  even  the  slightest 
excoriation  or  irritation  of  the  skin  beneath  the  jacket  can  be 
detected  by  the  peculiar  odor.     Of  this  parents  should  be  in- 


86 


OB  THOPEDIC  S  UR  GEE  Y. 


formed,  so  that  it  may  be  cut  down  and  the  source  of  the  irritation 
removed  at  once.  With  ordinary  care  "  sores,"  the  bugbear  of 
the  plaster  jacket,  may  be  avoided  or  so  quickly  detected  that 
they  are  of  little  consequence. 

If  the  disease  is  of  the  middle  region  of  the  spine,  backward 
traction  on  the  shoulders  is  indicated,  by  means  of  the  anterior 

Fig.  49. 


The  jury  mast  and  the  anterior  support. 

shoulder  brace  described  in  connection  with  the  spinal  brace 
(Fig.  49) ;  or,  if  this  is  not  at  hand,  padded  straps  may  be  passed 
about  the  shoulders  and  attached  to  buckles  placed  on  the  back 
of  the  jacket.  Traction  applied  in  this  manner  aids  in  prevent- 
ing deformity  and  assures  better  expansion  of  the  chest. 

In  many  instances  a  head  support  is  required,  and  it  is,  of 
course,  always  indicated  in  disease  of  the  upper  dorsal  and  cer- 
vical regions.  For  this  purpose  a  jury  mast  or  a  posterior  sup- 
port may  be  employed. 

The  jury  mast  should  be  of  tempered  steel,  strong  enough  to 
hold  its  shape  under  the  tension  of  the  halter  (Fig.  50).  Its 
base  should  be  incorporated  firmly  in  the  jacket  below  the  seat 
of  the  disease;  it  should  be  long  enough  to  reach  well  above 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


87 


the  head,  and  the  crossbar  should  be  placed  directly  over  the  ears 

(Fig.  53). 


Fig.  50. 


Jury  mast. 


Fig.  51. 


Fig.  52. 


A  fixation  support  for  the  head.   This  may  be 
used  with  the  brace  or  with  the  jacket. 


Front  view  of  the  same  patient. 


88  OR THOPEDIC  SUB  GEE  Y. 

The  halter  should  be  applied  with  as  much  teusiou  as  can  be 
borne  comfortably  by  the  patient,  so  that  the  weight  of  the  head 
may  be  at  least  partly  supported.  The  straps  should  be  ad- 
justed to  tilt  the  chin  slightly  upward,  the  aim  being  to  draw  the 
head  backward  and  thus  to  extend  the  spine.  Id  disease  of  the 
cervical  region  the  crossbar  should  be  fixed  to  check  lateral  mo- 
tion of  the  head,  but  this  is  unnecessary  when  the  disease  is  at  a 
lower  level. 

Fig.  riS. 


The  jacket  and  jury  mast  applied.    The  same  patient  is  shown  in  Fig.  32. 


If  more  complete  fixation  of  the  head  is  desired,  or  if  the  jury 
is  ineffective,  an  appliance  similar  to  that  shown  in  Fig.  51  may 
be  used.  This  consists  of  two  light  steel  bars,  incorporated  like 
the  jury  mast  in  the  jacket,  and  adjusted  to  the  necK  and  back 
of  the  head.  Their  upper  extremities  are  joined  by  a  band  of 
light  steel  of  U-shape,  long  enough  to  reach  from  ear  to  ear,  the 
circumference  being  completed  by  a  band  of  tape  across  the  fore- 
head. In  certain  instances  additional  straps  may  be  placed  be- 
neath the  chin  and  the  occiput,  as  in  Figs.  51  and  52.     In  this 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


89 


connection  it  may  be  stated  that  the  support  provided  Ijy  the  jury 
mast  is  only  effective  when  it  is  carefully  adjusted  and  carefully 
watched.  In  most  instances,  therefore,  a  rigid  apparatus,  though 
less  comfortable,  is  to  be  preferred. 


Fig.  54. 


The  application  of  the  jacket  in  the  recumbent  posture  by  means  of  the  Goldthwait  appli- 
ance. A,  the  support,  similar  to  that  upon  which  the  patient  is  lying  ;  B,  two  thin  bands  of 
steel,  similar  to  those  used  in  the  Taylor  brace. 


Fig.  55. 


•*"^I* 


nhMT' 


%  ^ 


R.  Tunstall  Taylor's  apparatus  for  the  application  of  the  plaster  jacket  in  the  recumbent 
posture,  consisting  of  an  adjustable  back  support  and  pelvic  rest  connected  by  a  sliding 
bar.    (See  Fig.  56.) 

The  Application  of  the  Jacket  in  the  Recumbent  Posture.  The 
jacket  may  be  applied  while  the  patient  lies  extended  in  the  prone 
iw.sturo,  by  the  Ji/vm/inooJc  method  suggested  by  Davy,  of  London. 


90 


ORTHOPEDIC  SURGERY. 


A  long,  narrow  strip  of  cotton  cloth  is  passed  under  the  shirt 
and  is  drawn  tight  enough,  by  means  of  a  pulley  or  by  manual 
traction,  to  support  the  child  in  the  proper  attitude,  preferably, 
of  course,  in  overextension.  An  opening  is  cut  for  the  face,  and, 
if  advisable,  traction  may  be  made  on  the  arms  and  legs  of  the 
patient.  The  bandages  are  then  applied  in  the  ordinary  manner, 
after  which  the  cloth  may  be  cut  short  at  one  end  and  removed. 

This  method  is  of  service  in  the  treatment  of  weak  or 
paralyzed  patients,  but  the  adjustment  is  somewhat  less  accurate 
than  by  the  ordinary  method.  The  jacket  may  be  applied  in 
the  supine  posture  by  means  of  the  Goldtkwait  apparatus.  This 
may  be  employed  with  advantage  in  the  routine  application  of 
the  plaster  jacket,  and  it  has  supplanted  in  some  degree  the  sus- 
pension method. 

Fig.  56. 


The  Taylor  appliance  in  use,  showing  the  hyperextension  of  the  spine.  The  plaster  jacket 
having  been  applied,  the  back  rest  is  removed  by  pressing  the  bandages  from  side  to  side  or 
by  enlarging  the  opening.    If  desirable,  the  defect  is  then  concealed  by  a  turn  of  plaster 


This  consists  essentially  of  a  support  (Fig.  54)  carrying  on  its 
upper  extremities  two  thin  strips  of  perforated  metal.  To  these 
strips,  felt  is  attached,  forming  pads  similar  to  those  used  on  the 
back  brace.  The  patient  is  then  placed  with  his  back  resting  on 
the  pads  at  the  seat  of  the  disease.  The  buttocks  and  the  head 
are  allowed  to  sink  downward  to  the  point  of  toleration,  thus  an 
extending  force  is  exerted  on  the  spine.  The  plaster  bandages 
are  then  applied  in  the  usual  manner  about  the  body  on  either 
side  of  the  support.  When  it  is  completed  the  patient  is  lifted 
from  the  support,  the  pads  being  included,  of  course,  in  the 
jacket.  An  opening  remains  at  this  point  that  may  be  closed  if 
desirable  by  an  additional  bandage. 

Other  supports  of  a  similar  nature  are  in  use,  but  as  they  do 
not  differ  from  it  in  principle  a  detailed  description  is  unneces- 
sary (Figs.  55  and  56). 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  91 

The  Application  of  the  Jacket  to  Patients  who  have  been  Treated 
on  the  Stretcher  Frame,  A  satisfactory  method  of  applying  a 
plaster  jacket  in  young  subjects,  when  the  deformity  has  been  cor- 
rected in  whole  or  part  by  recumbency  on  the  frame  in  the  over- 
extended position,  is  the  following :  The  patient  is  suspended 
face  downward  in  the  horizontal  position  by  two  assistants,  one 
holding  the  arms  and  the  other  the  thighs  ;  thus,  a  certain  amount 
of  traction  is  exerted,  while  the  weight  of  the  body  tends  to  over- 
extend  the  spine. 

In  this  attitude  a  jacket  is  quickly  applied,  and  the  child  is  at 
once  replaced  upon  his  frame,  which  has  been  protected  by  a 
rubber  sheet  (Fig.  57).  The  plaster  jacket,  during  the  hardening 
process,  must  conform  to  the  habitual  posture  of  recumbency. 
The  pressure  pads  of  the  frame  indent  the  bandage  on  either  side 
of  the  spinous  processes  (Fig.  58),  and  thus  afford  better  sup- 
port and  fixation.     This  is  a  very  satisfactory  method  of  apply- 

FlG.  57. 


The  stretcher  frame  on  which  the  patient  is  replaced  while  the  jacket  is  hardening. 

ing  the  jacket  in  this  class  of  cases,  because  it  is  not  necessary  to 
retain  the  child  in  an  uncomfortable  position  while  the  bandage 
is  hardening,  and  because  accuracy  of  adjustment  in  the  best 
possible  attitude  is  assured. 

These  methods,  in  which  the  object  is  to  overextend  the  spine, 
are  especially  indicated  in  cases  in  which  the  deformity  is  slight. 
If  it  is  fixed  and  well  marked,  suspension  is  preferable. 

As  a  rule,  a  jacket  may  be  worn  for  two  months,  although  not 
infrequently  it  may  remain  for  six  months,  or  even  longer,  and 
yet  be  fairly  efficient.  Usually  one  jacket  is  removed  and 
another  applied  on  the  same  day,  but  if  the  skin  is  at  all  sensitive 
it  is  well,  after  the  washing  and  powdering,  to  reapply  the  old 
jacket,  closing  it  with  adhesive  plaster,  and  allow  an  interval  of 
a  few  days  before  applying  the  permanent  one. 


92 


ORTHOPEDIC  SURGERY. 


The  Plaster  Corset.  In  the  stage  of  recovery  the  jacket  may 
be  replaced  by  a  corset.  A  jacket,  made  and  trimmed  as  already 
described,  is  cut  down  the  centre  and  removed  from  the  body. 
It  is  carefully  readjusted  to  its  former  shape,  bandaged  with  the 
cut  surfaces  in  close  apposition,  and  is  thoroughly  dried  or 
baked.  All  wrinkles  are  then  cut  away  from  the  inner  surface, 
and  extra  padding  is  applied  if  necessary  ;  the  shirt  is  drawn 
tightly  about  the  borders  of  the  jacket  and  strips  of  leather  pro- 
vided with  hooks  are  sewed  in  front  so  that  it  may  by  laced  like 
an  ordinary  corset.  It  may  be  removed  from  time  to  time  to 
allow  for  bathing,  but  it  should  always  be  removed  and  reapplied 
while  the  patient  is  suspended  or  in  the  recumbent  position. 


Fig.  58. 


Jacket  applied  by  the  stretcher  method,  showing  the  depressions  on  either  side  caused  by 

the  frame  pads. 

The  corset  is  sometimes  used  in  place  of  the  jacket  during  the 
active  stage  of  the  disease,  but  it  is  less  effective,  since  the  repeated 
stretching  during  removal  and  reai^plication  weakens  the  appli- 
ance and  impairs  the  accuracy  of  adjustment.  In  addition,  one 
of  the  strongest  arguments  in  favor  of  the  use  of  plaster  of  Paris, 
that  treatment  is  under  the  control  of  the  surgeon,  is  nullified. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  93 

Comparison  of  the  Two  Forms  of  Ambulatory  Support.  The 
most  severe  criticisms  of  the  jacket  have  been  made  by  those 
unfamiliar  with  its  use,  on  theoretical  grounds  rather  than  from 
actual  observation.  While  it  may  be  admitted  that  there  are 
certain  objections  to  the  support,  yet  experience  has  shown  that 
when  it  is  applied  in  a  proper  manner  under  proper  conditions  it 
is  a  thoroughly  reliable,  efficient,  and  often  indispensable  means 
of  treatment.  Indeed,  it  may  be  stated  that  by  means  of  the 
jacket  and  the  stretcher  frame  it  is  possible  to  treat  nearly  every 
case  of  Pott's  disease  without  the  aid  of  the  professional  brace- 
maker,  and  with  success. 

It  is  evident,  however,  that  under  certain  conditions  the  jacket 
must  be  inferior  to  the  brace,  in  early  childhood  for  example, 
when  the  pelvis  is  not  sufficiently  developed  for  proper  support. 
Again,  when  the  disease  is  low  down,  at  or  near  the  lumbosacral 
junction,  the  lower  border  of  the  jacket  does  not  hold  the  pelvis 
with  sufficient  security  to  provide  the  proper  fixation.  In  the 
upper  dorsal  region  the  attachments  for  accurate  fixation  may  be 
adjusted  more  readily  to  the  brace,  and  in  disease  of  the  cervical 
region  the  metallic  head  support  is  to  be  preferred  to  the  halter 
of  the  jury  mast,  for  the  reason  that  it  cannot  be  removed  by  the 
patient.  The  traction  of  the  jury  mast  is  very  effective  when 
properly  used,  and  particularly  so  when  painful  distortion  of  the 
head  is  present,  but  the  tension  on  the  straps  is  rarely  constant, 
and  thus  loses  in  efficiency.  A  rigid  support  is,  of  course,  prefer- 
able in  the  disease  of  the  atlo-axoid  region. 

The  jacket  is  most  serviceable  in  the  region  from  the  tenth 
dorsal  to  the  second  lumbar  vertebra.  It  is  not  only  effective, 
but  it  is  often  a  more  comfortable  support  than  the  spinal  brace. 
It  is  more  efficient  than  the  brace  when  lateral  deviation  of  the 
spine  is  present ;  and  from  the  clinical  standpoint  it  is  often  more 
efficacious  in  relieving  pain  in  this  region  when  the  disease  is  at 
all  acute.  One  may  conclude,  then,  that  each  form  of  support 
may  be  used  according  to  the  indications.  The  absolute  control 
of  the  treatment,  assured  by  the  use  of  the  plaster  jacket,  will 
often  overbalance  the  claims  of  the  brace.  In  practice  among 
the  poor,  when  choice  of  means  is  not  always  permitted,  it  is  indis- 
pensable ;  and  it  may  be  used  with  fair  success  even  under  con- 
ditions that  theoretically  coutraindicate  its  employment. 

Modifications  of  the  Jacket.  Occasionally,  the  form  of  the 
jacket  may  be  changed  to  meet  special  indications ;  for  example, 
backward  traction  may  be  secured  by  carrying  the  bandages  over 


94 


ORTHOPEDIC  SURQEBY. 


the  shoulders  ;  or  the  head  may  be  fixed  in  the  support,  i£  the 
jury  mast  is  not  at  hand  (Fig.  59) ;  or  one  or  both  thighs  may 
be  inchided  in  a  spica  jacket  in  painful  disease  of  the  lower  region, 
when  psoas  spasm  is  jiresent.  Such  modifications  are  required 
rather  for  emergencies  than  for  continuous  treatment. 

Dr.  H.  L.  Taylor  has  recommended  what  he  calls  the  bivalve 
plastic  splint  of  plaster  of  Paris. 

''  A  paper  pattern  of  the  posterior  valve  is  made  from  the 
patient's  back,  allowing  one  inch  extra  around  the  edge  to  be 


Fig.  59. 


Plaster  bandage  including  the  head  to  hold  the  spine  In  the  extended  position,  as  applied  for 
disease  of  the  upper  dorsal  region. 

folded  back.  From  this  pattern  eight  or  ten  thicknesses  of 
crinoline  are  cut  of  the  same  size  and  shape.  The  patient  being 
supported  face  downward  on  a  rest  under  the  pelvis  and  another 
under  the  upper  part  of  the  sternum,  the  crinoline  sheets  are 
dipped  into  plaster  cream  in  a  large  flat  pan,  applied  to  the  back, 
the  felt  pads  being  in  position ;  the  edges  are  folded  back  for 
greater  rigidity  and  the  whole  carefully  moulded  to  the  patient 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  95 

and  allowed  to  set,  after  which  the  patient  is  turned  on  his  back 
and  the  anterior  valve  made  in  a  similar  manner. 

"  The  support  should  be  made  firm  and  rigid,  especially  at  the 
edges,  and  should  reach  in  front  from  the  pubes  to  the  top  of  the 
sternum.  Such  an  apparatus  is  rigid,  removable,  and  adjustable, 
and  brings  the  pressure  to  bear  on  definite  areas  selected  with 
regard  to  its  mechanical  action.  The  splint  may  be  removed  to 
cleanse  the  back  or  to  note  its  efficiency,  taking  the  impressions 
made  by  the  felt  pad  either  side  the  spinous  processes  as  a  guide. 
If  more  leverage  is  needed,  the  felting  may  be  reinforced  or  the 
depth  of  casing  reduced  by  paring  the  lateral  edges.  In  other 
words,  the  jacket  has  ceased  to  be  mainly  a  casing  and  has  become 
a  mechanism  under  the  surgeon's  control  and  capable  of  being 
manipulated  to  produce  definite  mechanical  results." 

Corsets  of  Other  Material  Than  Plaster  of  Paris.  Corsets  of 
wood,  leather,  paper,  poroplastic  felt,  and  celluloid  are  sometimes 
used.  These  are  constructed  on  a  plaster  cast  of  the  body,  a 
thin,  accurately  fitting  jacket  being  used  as  a  mould. 

Fig.  60. 


The  Thomas  collar  of  leather  stuffed  with  cotton.    (Ridlon  and  Jones.) 

Such  corsets  have  certain  advantages  of  durability  and  elegance, 
but  none  of  them  has  the  accuracy  of  fit  of  the  plaster-of-Paris 
corset,  which  is  moulded  directly  on  the  body  by  constant  manipu- 
lation during  the  stage  of  solidification.  Corsets  of  this  class  are 
usually  somewhat  expensive,  and  on  that  account  are  often  worn 
after  they  are  outgrown  or  when  they  no  longer  fit  the  patient. 
Their  use  is  practically  limited  to  the  stage  of  recovery  or  for 
other  affections  than  Pott's  disease. 

Of  these  corsets,  one  of  the  best  is  that  used  by  Weigel,  of 
Rochester,  made  of  alternate  layers  of  linen  cloth  and  wood-pulp 
matrix  paper,  fixed  by  a  mixture  of  paste  and  glue. 

A  more  durable  corset  may  be  constructed  of  aluminum,  as 
suggested  by  Phelps.  This  may  be  obtained  in  thin  sheets, 
which  may  be  hampered  upon  a  metal  cast  of  the  trunk  into  the 
proper  shape.  The  two  halves  are  attached  by  hinges  in  the 
back  and  are  perforated  to  allow  for  ventilation. 

In  the  final  stage  of  treatment,  the  Knight  brace,  a  light  steel 


96  ORTHOPEDIC  SURGERY. 

frame  with  corset  front,  may  be  employed  (Fig.  143)  or  a  long 
corset  similar  to  that  ordinarily  worn  by  women,  but  strengthened 
by  the  insertion  of  light  steel  bars  along  the  spine,  may  be  sufficient. 

Other  Forms  of  Support.  In  certain  cases  of  disease  of  the  lower 
lumbar  region  of  the  spine  it  may  seem  advisable  to  restrain  the 
movements  of  the  thighs,  although  ordinarily,  when  this  is  neces- 
sary, ambulation  should  be  discontinued.  Such  restraint  may  be 
attained  by  making  the  back  bars  of  the  brace  stronger  and 
extending  them  down  the  back  of  the  thighs  to  the  knees  like  a 
double  Thomas  hip  brace. 

If  the  jacket  is  used  it  may  be  extended  to  a  single  or  double 
spica  for  the  same  purpose  as  has  been  mentioned.  Such  appli- 
ances are  useful  when  psoas  spasm  and  ^'  cramp  "  are  troublesome 
symptoms. 

Fig.  61. 


The  Thomas  collar  for  permanent  use.  A  piece  of  thin  sheet  metal  is  cut  wide  enough 
to  reach  from  the  sternum  to  the  chin,  and  from  the  back  of  the  neck  to  the  base  of  the 
occiput.  The  edges  are  turued  out  and  the  whole  properly  covered  with  felt  and  fitted. 
(Ridlon  and  Jones.) 

In  disease  of  the  cervical  region  a  certain  amount  of  support 
and  fixation  may  be  obtained  by  collars  of  poroplastic  felt, 
plaster  of  Paris,  or  other  material.  The  Thomas  collar  (Figs.  60 
and  61)  is  the  best  of  this  type  of  support,  but  none  of  them  is 
thoroughly  efficient  unless  used  with  a  brace  to  control  the  larger 
movements  of  the  spine.  They  are  useful  in  emergencies,  but 
they  are  not  often  required  when  proper  braces  can  be  obtained. 

Many  other  forms  of  apparatus  of  greater  or  less  merit  might 
be  described,  but  space  has  permitted  only  a  detailed  account  of 
three  forms  that,  it  would  seem,  best  represent  the  essential  prin- 
ciples involved  in  the  treatment  of  Pott's  disease. 

The  Principles  of  Treatment  in  Their  Practical  Application. 
After  the  description  of  the  special  forms  of  appliances  used  in 
the  routine  treatment  of  Pott's  disease,  one  may  consider  with 
advantage  the  treatment  in  its  more  direct  relation  to  the  patient. 
The  object  of  this  treatment  is  to  relieve  the  symptoms,  to  main- 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


97 


tain  and  to  improve  the  vital  resistance  of  the  patient,  to  check, 
to  remedy,  and  to  prevent  deformity.  Under  favorable  con- 
ditions the  death-rate  is  small,  and  pain  is  easily  relieved,  but 
prevention  of  deformity  is  often  extremely  difficult. 

The  effect  of  treatment  must  be  estimated  not  simply  by  its 
relief  of  the  symptoms  of  the  disease,  since  deformity  may  steadily 
advance  in  spite  of  the  apparent  well-being  of  the  patient,  but  it 
must  be  selected  and  continued  or  changed  with  the  aim  of  com- 
bating ultimate  deformity,  and  on  this  standard  success  or  failure 
must  be  determined.     It  is  probable  that  noticeable  deformity 


Fig.  62. 


The  Thomas  collar  applied.    (Rldlon  and  Jones 


might  be  prevented,  nearly  always,  if  treatment  were'applied  in 
season.  But  practically  such  opportunity  is  not  often  'offered, 
and  the  local  deformity  that  represents  destruction  of  bone  may 
be  considered  as  irremediable.  There  is  also  a  dwarfing  and 
blighting  effect  of  the  disease,  which,  although  it  is  usually  asso- 
ciated with  marked  deformity,  is  always  to  be  feared,  particularly 
when  the  disease  affects  the  middle  or  lower  region  of  the  spine 
in  early  childhood,  and  is  severe  and  prolonged  in  its  course. 
By  proper  treatment  one  may  hope  to  check  the  progress  of  the 
disease  and  even  to  remedy  the  deformity  in  great  degree  by  free- 
ing the  spine  from  the  deforming  influence  of  local  disease,  and 

7 


98 


ORTHOPEDIC  SURGERY. 


by  preventing  or  removing  the  symptomatic  distortions  such  as 
psoas  contraction  or  wryneck. 

Indications  for  Treatment  by  Recumbency.  As  has  been  stated 
already,  the  most  important  influence  toward  deformity  when  the 
spine  has  been  weakened  by  disease  is  the  force  of  gravity  ; 
therefore,  horizontal  fixation  in  overextension  is  the  most  efficient 
means  of  preventing  deformity,  and  it  assures  the  rest  for  the 
diseased  spine  that  favors  repair. 


Fig.  63. 


< 

t 

?BSBS^^?^B^^^|^^^^^^^. 

^^,^^BKII^^^^Uk 

Pott's  disease  of  the  middle  dorsal  region,  a  type  of  disease  in  which  horizontal 
fixation  is  always  indicated.    H.  S.,  aged  fourteen  months. 


This  is  always  the  treatment  for  emergencies  and  in  many 
instances  the  treatment  of  choice  and  routine.  It  is  indicated  as 
the  routine  treatment  in  infancy  and  in  early  childhood  up  to  the 
age  of  three  years  at  least. 

In  many  instances  absolute  recumbency  may  not  be  required, 
but  the  period  of  activity  must  be  carefully  regulated,  and  must 
be  discontinued  when  there  is  evidence  of  discomfort  or  weakness 
or  pain.  If  the  period  of  activity  must  be  short,  it  should  be 
passed  in  the  open  air.  The  passive  attitude  of  sitting,  although 
less  strain  is  thrown  upon  the  spine  than  during  activity,  may  be 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


99 


even  worse  for  the  patient ;  thus,  the  reclining  or  semi-reclining 
posture  should  be  assumed  as  a  rule,  when  the  child  is  in  the 
house,  at  least  during  the  active  stage  of  the  disease.  Even  if 
the  spine  appears  to  be  perfectly  supported,  the  time  spent  in 
bed  should  be  long,  and  a  period  of  rest  in  the  middle  of  the  day 
should  be  enforced. 

The  arguments  in  favor  of  horizontal  fixation  in  early  child- 
hood do  not  apply  to  disease  in  the  adult.  At  this  stage  the 
structure  of  the  spine  is  resistant,  and  deformity  is  little  to  be 
feared,  while  such  confinement  would  be  irksome  and  impracti- 
cable ;  thus,  local  support,  supervision,  and,  if  possible,  a  change 


Fig.  64. 


H.  S.,  after  fourteen  months  of  fixation  on  the  modified  Bradford  frame,  shows 
the  recession  of  deformity.    Compare  with  Fig.  63. 

of  climate,  must  be  the  treatment  of  selection  for  the  adolescent 
or  adult. 

In  the  middle  period  of  childhood,  from  the  fifth  to  the  tenth 
year,  horizontal  fixation  is  the  treatment  for  emergencies ;  for 
paralysis,  for  abscess,  for  dangerous  disease  of  the  atlo-axoid 
region,  for  progressive  deformity,  and  for  pain  that  cannot  be 
relieved  by  the  ordinary  means. 

Special  Indications  for  Treatment  of  Disease  of  the  Differ- 
ent Regions  of  the  Spine.  In  the  selection  of  treatment,  and 
in  the  general  management  of  Pott's  disease,  each  region  of  the 
spine  must  be  judged  by  itself,  since  in  each  there  are  special 
difficulties  to  be  met,  and  complications  to  be  feared  that  may 


100 


OR THOPEDIC  SUBGEB  Y. 


Fig.  65, 


influence  the  prognosis  and  lead  to  modifications  of  the  routine  of 
treatment. 

The  Lower  Region.  The  prognosis  is  good  in  disease  of  the 
lower  region,  the  symptomatic  attitude  is  favorable,  the  part  may- 
be supported  easily,  the  cases  are  often  seen  before  the  deformity 
is  at  all  extreme,  and  one  may,  as  a  rule,  predict  recovery  with- 
out noticeable  deformity,  at  most, 
but  a  slight  shortening  and  broad- 
ening of  the  body  and  a  peculiar 
erectness  of  attitude.  Uncomplicated 
cases  may  be  treated  with  the  brace 
or  jacket.  The  brace  is  the  better 
support  when  the  disease  is  near  the 
sacrum,  while  the  jacket  is  often 
more  comfortable  and  more  effective 
than  the  brace  when  the  middle  or 
upper  lumbar  region  is  diseased,  par- 
ticularly when  lateral  deviation  of 
the  spine  is  present.  Whenever  the 
tendency  to  psoas  contraction  is  at 
all  marked  or  when  pain  or  cramps 
in  the  legs  are  complained  of,  the 
period  of  activity  should  be  care- 
fully restricted;  in  fact,  the  ''night 
cry "  is  an  indication  for  a  day  of 
rest  in  bed. 

The  most  troublesome  complica- 
tions of  this  region  are  psoas  con- 
traction and  the  abscess  with  which 
it  is  often  combined. 

As  has  been  stated,  psoas  contrac- 
tion   changes   the  attitude  of   over- 
erectness,   favorable  to   repair,  to  a 
Final  result  of  lumbar  disease  ;spon-   forward    stoop    that    increases    the 
taneous  absorption  of  abscess,  and  but   pressure  aud  friction  at  the  seat  of 

slight  deformity.    (See  Fig.  13.)  ^_ 

disease.  If  this  attitude  persists  and 
if  it  becomes  fixed  by  permanent  changes  such  as  are  likely 
to  follow  the  burrowing  of  a  pelvic  abscess,  most  disastrous 
deformity  may  follow ;  the  body  and  the  thighs  are  approx- 
imated and  the  erect  attitude  is  made  impossible.  In  neglected 
cases  of  this  character,  tenotomy  and  forcible  correction  or  even 
subtrochanteric   osteotomy   may   be    necessary   to   overcome  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  IQl 

secondary  deformity.  In  ordinary  cases  of  psoas  contraction, 
and  when  one  limb  only  is  flexed,  the  patient  may  be  allowed  to 
go  about  using  a  high  shoe  on  the  unaffected  side,  and  crutches, 
so  that  the  flexed  leg  need  not  affect  the  attitude.  If,  however, 
the  contraction  persists,  it  is  well  to  place  the  patient  on  a  frame, 
and  to  reduce  the  flexion  by  traction  in  the  line  of  deformity,  as 
will  be  described  in  the  treatment  of  disease  of  the  hip-joint. 
Persistent  psoas  contraction  is  almost  always  a  symptom  of 
abscess  about  the  origin  or  in  the  substance  of  the  muscle,  and 
when  it  is  accompanied  by  pain  it  is  always  an  evidence  of  pro- 
gressive disease. 

Abscess  may  be  expected  as  a  complication  in  at  least  50  per 
cent,  of  the  cases  of  disease  of  this  region,  but  it  is  by  no  means 
always  accompanied  by  psoas  contraction,  any  more  than  psoas 
contraction  is  always  caused  by  abscess.  Abscess  unaccompanied 
by  contraction  more  often  has  its  origin  above  the  lumbar  region, 
and  in  its  descent  it  passes  along  the  surface  without  involving 
the  substance  of  the  muscle. 

Attention  is  especially  called  to  the  fact  that  the  bad  results  of 
Pott's  disease  of  this  region  are  caused  almost  invariably  by 
allowing  psoas  contraction,  whether  it  be  symptomatic  of  abscess 
or  not,  to  persist ;  therefore,  the  importance  of  preventing  and 
correcting  this  deformity  cannot  be  overestimated.  It  should  be 
stated,  however,  that  in  dispensary  practice,  when  special  care 
cannot  be  provided,  one  often  sees  psoas  contraction  that  may 
have  persisted  for  months  relax,  if  the  progress  of  the  disease  is 
favorable,  without  treatment  other  than  the  routine  fixation  of 
the  spine  by  the  brace  or  jacket. 

The  Lower  Dorsal  Region.  Disease  of  the  lower  dorsal  region 
is  very  favorably  situated  for  effective  mechanical  treatment,  and 
psoas  contraction  and  abscess  are  much  less  troublesome  than  in 
the  lower  part  of  the  spine. 

Deformity  sometimes  increases,  almost  imperceptibly,  by  a 
progressive  forward  bending  or  lordosis  of  the  flexible  lumbar 
spine  below  the  projection.  One  must  guard  against  this  by 
applying  the  jacket  firmly  while  the  spine  is  made  as  straight  as 
possible,  or,  if  the  brace  is  used,  the  lumbar  spine  should  be 
drawn  firmly  against  it. 

If  lateral  inclination  of  the  body  is  so  marked  as  to  interfere 
with  the  proper  application  of  a  brace,  preliminary  rest  in  bed  is 
indicated.  Lateral  deviation  can  be  corrected,  as  a  rule,  by  the 
jacket  without  recumbency,  although  this,  as  other  forms  of  symp- 


102  ORTHOPEDIC  SURGERY. 

tomatic  distortion,  should  be  treated  ordinarily,  if  not  by  complete 
rest,  at  least  by  careful  regulation  of  the  period  of  activity. 

Disease  of  the  Middle  and  Upper  Dorsal  Region,  This  is,  from 
the  standpoint  of  prevention  of  deformity,  the  most  difficult 
region  of  the  spine  to  treat,  although  the  symptoms  of  the  disease 
may  be  easily  relieved. 

Deformity  is  present  in  nearly  all  cases  when  treatment  is 
sought,  and,  deformity^  having  begun,  is  very  difficult  to  check, 
for  the  reasons  that  have  been  stated  already. 

The  final  result  in  the  majority  of  cases  is  what  appears  to  be 
exaggerated  round  shoulders ;  the  neck  is  shortened  and  projects 
forward,  the  chest  is  flat,  and  the  shoulders  are  high. 

It  is  only  by  an  early  diagnosis  and  by  efficient  and  long- 
continued  treatment,  beginning,  if  practicable,  with  horizontal 
fixation,  that  recovery  from  disease  in  this  region  without  notice- 
able deformity  may  be  hoped  for. 

In  all  cases  of  disease  above  the  ninth  vertebra,  the  anterior 
brace  for  backward  traction  of  the  shoulders  may  be  used  with 
great  advantage  to  secure  greater  fixation  of  the  spine  ;  and  in  all 
cases  above  the  seventh  or  eighth  vertebra  a  head  or  chin  support 
to  restrain  the  forward  inclination  of  the  neck  is  indicated  in 
addition. 

With  the  plaster  jacket  the  jury  mast  or  posterior  support  is 
employed ;  with  the  brace  the  looped  chin  rest  or  the  ordinary 
Taylor  support  may  be  used. 

In  disease  of  the  upper  dorsal  region  the  brace  is  to  be  preferred 
to  the  jacket,  because  of  the  greater  accuracy  of  adjustment,  and 
because  the  halter  of  the  jury  mast  is  rarely  retained  in  proper 
position  when  the  patient  does  not,  as  in  these  cases,  feel  the 
need  of  such  support. 

In  this  region  of  the  spine  paralysis  frequently  occurs  as  a 
complication.  When  it  appears  after  treatment  is  begun,  it  is 
usually  a  result  of  inefficient  fixation  of  the  spine  or  of  want  of 
caution  in  regulating  the  strain  to  which  the  diseased  part  is 
subjected.  Its  symptoms  and  its  treatment  will  be  considered 
later. 

Disease  of  the  Upper  Dorsal  and  Middle  Cervical  Region.  This 
is  the  most  favorable  region  of  the  spine  for  treatment.  The 
disease  is  usually  not  extensive  because  of  the  small  size  and  com- 
pact structure  of  the  vertebrae ;  and  the  mobility  of  the  cervical 
region  is  so  great  that  it  readily  compensates  for  the  local  rigidity. 

Under  efficient  treatment  one  may  predict  recovery  without 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  103 

noticeable  deformity,  and  in  the  less  successful  cases  the  deform- 
ity is  not,  as  a  rule,  offensive.  The  shoulders  appear  high,  the 
neck  is  short,  the  head  inclines  forward,  while  the  back  is  abnor- 
mally flat  in  compensation  for  the  change  in  contour  of  the  part 
above. 

When  the  case  of  cervical  disease  is  first  brought  for  treatment 
a  W7'yneck  deformity,  often  made  more  persistent  by  the  infiltra- 
tion of  an  abscess  or  by  enlarged  cervical  glands,  is  almost  always 
present.  As  a  means  of  correcting  this  distortion,  the  jury  mast 
and  traction  halter,  attached  to  the  jacket  or  brace,  is  a  very 
efficient  and  comfortable  support.  Under  the  constant  tension 
the  deformity  may  be  corrected  with  ease,  but  as  a  permanent 
treatment  the  brace  and  head  support  are  to  be  preferred  to  the 
jury  mast,  because  a  more  exact  fixation  is  assured. 

Disease  of  the  Occipito-axoid  Region.  Under  efficient  treatment 
the  prognosis  is  good,  and  recovery  without  deformity  should  be 
the  rule.  The  course  of  the  disease,  although  it  is  often  accom- 
panied by  acute  symptoms,  is  usually  short,  as  compared  with 
that  of  other  regions  of  the  spine.  It  may  be  assumed  that,  in 
many  cases,  it  is  a  primary  arthritis,  or,  at  least,  that  the  primary 
focus  in  the  atlas  or  axis  is  very  small.  The  disease  at  this  point 
is,  however,  in  close  proximity  to  the  vital  centres,  and  sudden 
death  from  displacement  of  the  weakened  parts  is  not  uncommon. 
Abscess  is  frequent,  and  it  is  often  a  troublesome  and  dangerous 
complication. 

As  has  been  mentioned,  wryneck  deformity  is  a  very  constant 
symptom,  and  there  is  also  a  strong  tendency  toward  a  forward 
and  downward  inclination  of  the  head,  so  that  in  neglected  cases 
the  chin  may  rest  upon  the  chest.  The  indications  for  treatment 
are  to  overcome  the  distortion  and  to  hold  the  head  fixed  in  the 
middle  line,  the  chin  being  somewhat  elevated  above  the  right- 
angled  relation  with  the  spine.  In  the  mild  cases  the  jacket  with 
jury-mast  traction  may  be  used  to  overcome  the  distortion,  but 
the  metallic  head  support  with  the  fixation  attachment  to  prevent 
motion  in  the  diseased  joints,  is  always  indicated  as  the  treatment 
of  selection,  because  by  such  apparatus  the  danger  of  displacement 
may  be  avoided. 

When  the  disease  is  acute  in  character,  and  especially  if  abscess 
is  present,  recumbency  on  the  frame  with  fixation  of  the  head  and 
slight  traction  by  the  weight  and  pulley,  or  by  the  jury-mast 
attachment,  is  indicated.  Traction  should  not  be  sufficient  to 
cause  discomfort ;  counter-traction  may  be  supplied  by  the  weight 


1 04  OB  THOPEDIG  S  UB  GEB  Y. 

of  the  body  and  by  slight  elevation  of  the  head  of  the  bed.  The 
head  sling  may  be  that  used  with  the  jury  mast,  or  a  simple 
band  about  the  head  may  be  used.  Under  this  treatment  slight 
deformity  of  any  part  of  the  cervical  region  will  practically  dis- 
appear, and,  as  a  rule,  the  course  of  the  disease  is  very  favorably 
influenced  by  the  period  of  complete  rest. 

In  certain  cases  of  disease  of  this  region,  accompanied  by  acute 
symptoms,  the  attitude  of  recumbency  is  extremely  uncomfortable. 
The  discomfort  is  caused  apparently  by  the  forward  projection  of 
the  upper  part  of  the  spine,  so  that  when  the  head  is  drawn 
upward  and  backward  in  the  recumbent  attitude  the  calibre  of  the 
throat  is  lessened.  In  other  instances  the  pain  may  be  due  to 
pressure  of  the  atlas  against  the  odontoid  process  of  the  axis.  In 
such  cases,  if  recumbency  is  desired,  the  head  must  be  elevated 
by  pillows  to  the  point  of  comfort,  the  support  being  removed 
when  the  child  has  become  accustomed  to  the  position,  or  when 
the  deformity  has  been  corrected. 

The  Complications  of  Pott's  Disease.  Abscess.  It  may  be 
assumed  that  a  limited  collection  of  tuberculous  fluid  is  present 
at  some  time  during  the  course  of  Pottos  disease  in  the  great 
majority  of  cases,  but  unless  it  appears  as  a  palpable  tumor  above 
or  below  the  thorax  or  upon  the  surface  of  the  body  its  presence 
is  not  often  detected. 

Townsend,^  in  380  cases  of  Pott's  disease  examined  with  refer- 
ence to  the  occurrence  of  abscess  as  a  complication,  found  that  it 
was  present  or  had  been  detected  in  75  (19.7  per  cent.);  in  8 
per  cent,  of  the  cases  of  cervical  disease ;  in  20  per  cent,  of  the 
dorsal,  and  in  72  per  cent,  of  those  in  which  the  lumbar  region 
was  involved. 

Dollinger,^  in  700  cases  under  treatment  from  1883  to  1895, 
found  abscess  in  154  (22  per  cent.);  in  13  of  63  cases  in  the 
cervical  region  (22.6  per  cent.) ;  in  47  of  403  cases  in  the  thoracic 
region  (11.6  per  cent.),  and  in  94  of  234  cases  of  lumbar  disease 
(40.17  per  cent.). 

Ketch,^  in  75  cured  cases  of  Pott's  disease  treated  at  the  New 
York  Orthopedic  Dispensary,  selected  for  the  purpose  of  con- 
trasting the  behavior  of  the  disease  in  the  different  regions  of  the 
spine,  found  that  abscess  had  appeared  in  19  (25.3  per  cent.). 
In  the  upper  region  abscess  was  detected  in  but  1  of  the  25  cases 

1  Transactions  American  Orthopedic  Association,  vol.  iv.  p.  166. 

-  Log.  cit. 

3  Transactions  American  Orthopedic  Association,  vol.  iv.  p.  200. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  105 

(4  per  cent.) ;  in  the  middle  region  in  8  of  the  25  cases  (32  per 
cent.),  and  in  the  lower  in  10  (40  per  cent.). 

In  354  autopsies  by  Mohr,  Nebel  Bouvier,  and  Lannelongue 
abscess  was  found  in  281,  or  nearly  80  per  cent.  Although 
cases  of  Pott's  disease  that  come  to  autopsy  may  be  supposed  to 
represent  a  severe  type  of  disease,  yet  it  is  evident,  by  contrasting 
the  statistics,  that  a  large  proportion  of  the  abscesses  escape  detec- 
tion in  the  living.  One  may  conclude,  then,  that  abscess  may  be 
expected  as  a  more  or  less  serious  complication  in  25  per  cent,  of 
all  cases  of  Pott's  disease,  and  in  at  least  half  of  those  in  which 
the  lower  region  of  the  spine  is  involved.  The  greater  frequency 
here  is  explained  by  the  large  size  and  less  resistant  structure  of 
the  vertebral  bodies,  as  compared  with  those  of  the  upper  regions. 

The  tuberculous  abscess  is  separated  from  the  neighboring 
parts  by  a  limiting  wall  varying  in  thickness  according  to  its 
age,  the  outer  layers  of  which  are  of  fibrous  and  cellular  tissue, 
the  inner  of  granulation  tissue  covered  with  yellowish-gray  or 
pinkish-gray,  necrotic  membrane,  which  is  easily  separated  from 
the  underlying  parts.  The  fluid  of  the  abscess  is  usually  of  a 
whitish  or  whey-like  color,  composed  of  serum,  leucocytes,  and 
emulsified  caseous  material  and  fibrin.  Floating  in  it  are  large 
masses  of  cheesy,  necrotic  tissue  and  sometimes  minute  fragments 
of  bone,  which  settle  to  the  bottom  of  the  glass  if  the  fluid  is 
allowed  to  stand.  Certain  of  the  smaller  quiescent  abscesses 
contain  only  this  whitish  semi-solid  material.  The  fluid  of 
abscesses  in  process  of  resolution  is  often  clear,  like  serum,  but 
if  secondary  infection  has  taken  place  the  pus  is  of  a  greenish- 
yellow  color,  and  is  of  uniform  consistency.  At  any  stage  of  its 
progress  the  abscess  may  become  stationary  and  its  contents  may 
be  absorbed,  in  fact,  such  an  outcome  is  not  unusual.  The  fluid 
of  the  abscess  is  usually  sterile,  and  secondary  infection,  before  a 
communication  with  the  exterior  of  the  body  is  established,  is 
comparatively  uncommon. 

It  has  been  claimed  that  abscess  formation  is  always  the  result 
of  infection  with  pyogenic  germs,  but  this  may  be  doubted,  since 
the  ordinary  tuberculous  abscess  may  be  sterile  or  at  most  contain 
but  a  few  tubercle  bacilli.  It  is  certain,  on  the  other  hand,  that 
the  formation  and  increase  of  the  abscess  is  favored  by  irritation 
and  injury,  and  that  the  most  effective  treatment  of  this  compli- 
cation is  to  support  the  diseased  spine  and  to  relieve  it  from 
overstrain. 

Abscess  is  a  symptom  of  disease,  and  it  is  in  some  degree  an 


106  ORTHOPEDIC  SURGERY. 

evidence  of  its  character.  If  it  appears  early  and  increases  in 
size  rapidly,  it  usually  indicates  a  destructive  and  rapidly  advanc- 
ing process,  or  infection  from  without.  On  the  other  hand,  the 
slowly  enlarging  or  quiescent  abscess  has  but  little  significance. 

In  many  instances  the  abscess  causes  no  symptoms  whatever, 
or  it  may  be  a  source  of  inconvenience  simply  because  of  its  size 
or  situation.  In  other  cases  a  period  of  malaise  or  discomfort  or 
pain  is  followed  and  explained  by  the  appearance  of  an  abscess, 
but  whether  the  symptoms  are  caused  by  the  tension  of  the 
abscess  or  by  a  more  acute  phase  of  the  disease  itself  is  not  always 
clear. 

Large  abscesses  that  are  increasing  in  size  and  approaching  the 
surface  are  usually  accompanied  by  pain  and  by  elevation  of 
temperature.  This  indicates,  probably,  a  slight  degree  of  second- 
ary infection,  but  the  ordinary  deep  abscess  appears  to  have  no 
other  effect  than  to  add,  doubtless,  to  the  susceptibility  of  the 
patient. 

The  Course  and  Peculiarities  of  Abscess  in  the  Different  Regions 
of  the  Spine.  The  tuberculous  abscess  may  remain  as  a  small 
collection  of  fluid  in  the  neighborhood  of  the  diseased  area.  As 
a  rule,  however,  it  slowly  increases  in  size,  and  under  the  in- 
fluences of  the  force  of  gravity  and  the  tension  of  its  contents  it 
finds  its  way  down  the  spine  or  toward  the  exterior  of  the  body, 
following  the  path  of  least  resistance.  The  abscesses  which  have 
passed  below  the  diaphragm  or  which  have  originated  below  this 
point  may  follow  various  paths.  Some  enter  the  sheath  of  the 
psoas  muscle,  and,  finally,  make  their  appearance  on  the  inner 
aspect  of  the  thigh,  psoas  abscess.  Others  perforate  the  sheath  of 
the  quadratus  lumborum  muscle  and  form  a  lumbar  abscess, 
projecting  between  the  twelfth  rib  and  the  crest  of  the  ilium  at 
the  triangle  of  Petit.  Those  abscesses  that  escape  from  the  fascia 
of  the  psoas  muscle  or  that  pass  downward  on  the  surface  of  the 
iliac  fascia,  the  so-called  iliac  abscesses,  may  appear  as  a  tumor 
over  the  outer  extremity  of  Poupart's  ligament  at  the  junction  of 
the  transversalis  and  iliac  fasciae,  or  the  fluid  may  follow  the 
course  of  the  iliac  artery  to  the  thigh,  or,  escaping  from  the 
greater  sacrosciatic  foramen,  form  a  gluteal  abscess. 

Iliac  or  psoas  abscess  is  most  often  confined  to  one  side,  but  it 
may  be  bilateral,  the  two  sacs  communicating  with  one  another 
by  a  larger  or  smaller  channel.  In  the  thoracic  region  the  abscess 
may  remain  indefinitely  in  the  posterior  mediastinum,  where,  if 
large,  its  presence  may  be  demonstrated   by  an  area  of  dulness 


TUBERCULOUS  DISEASE  OF  THE  SPINE. 


107 


extending  toward  the  lateral  region  of  the  thorax,  or  it  may  per- 
forate the  intercostal  muscles  and  appear  on  the  posterior  or  lateral 
aspect  of  the  chest,  or  it  may  pass  downward  through  the  aortic 
opening  in  the  diaphragm  and  become  an  iliac  abscess. 

Abscess  caused  by  disease  of  the  occipito-axoid  region  may 
force  its  way  forward  between  the  recti  muscles  and  appear  behind 
the  pharynx  as  the  retropharyngeal  abscess,  or  the  fluid  may  take 


Fig.  66. 


Bilateral  lumbar  abscess. 


the  opposite  direction  and  distend  the  suboccipital  triangle  and 
then  pass  forward  to  the  region  of  the  mastoid  process.  In  other 
instances  the  abscess  may  dissect  its  way  about  the  base  of  the 
skull  or  pass  upward  through  the  foramen  magnum  or  downward 
into  the  spinal  canal. 

Abscesses  from  the  middle  cervical  region  usually  pass  outward 
between  the  scaleni  and  longus  colli  muscles  to  the  interval 
between  the  trapezius  and  sterno mastoid,  perforating  the  skin 
about  the  middle  of  the  lateral  aspect  of  the  neck  near  the  anterior 
border  of  the  latter  muscle. 


108  ORTHOPEDIC  SUBGEBY. 

These  are  the  paths  usually  followed  by  the  tuberculous  fluid, 
but  occasionally  it  may  enter  the  spinal  canal  or  break  into  the 
pleural  cavity  or  lung  or  intestine  or  by  the  side  of  the  rectum  or 
elsewhere. 

Treatment  of  Abscess.  Abscess  is  by  far  the  most  troublesome 
and  dangerous  complication  of  Pott's  disease.  It  may  interfere 
with  proper  mechanical  treatment,  and  it  is  often  a  cause  of 
permanent  as  well  as  temporary  deformity,  especially  in  the  lower 
region  of  the  spine,  as  has  been  stated.  It  prolongs  the  course 
of  the  disease  by  extending  its  boundaries,  and,  although  it  is 
not  often  a  direct  cause  of  death,  yet  many  patients  die  because 
of  the  exhaustion  of  long-continued  suppuration  that  may  follow 
secondary  infection,  and  of  the  amyloid  degeneration  that  may 
finally  result. 

A  large  abscess  is  always  a  source  of  danger  because  of  the 
possibility  of  secondary  infection  of  its  contents  before  it  finds 
an  outlet,  and  because  of  the  probability  of  infection  when  a  com- 
munication with  the  exterior  has  been  established.  Abscess  is, 
however,  a  symptom  and  result  of  disease,  and  in  properly 
treated  cases  it  is,  as  a  rule,  a  complication  of  comparatively 
slight  consequence.  If  it  is  not  present  when  treatment  is  begun, 
one  may  hope  to  prevent  it  by  effective  protection  of  the  spine, 
and  if  it  is  present,  this  protection  should  be  all  the  more  rigidly 
enforced.  An  abscess  often  exists  for  months  before  its  presence 
is  detected,  and  after  its  discovery  it  may  remain  quiescent  for  a 
long  time,  and  finally  disappear. 

In  a  very  large  proportion  of  cases  the  abscess  causes  no  symp- 
toms, but  slowly  finds  its  way  to  the  surface  of  the  body.  Mean- 
while it  may  be  assumed  that  the  disease  of  the  spine,  of  which 
the  abscess  is  a  result,  is  in  process  of  cure;  so  that  when  the 
fluid  finds  an  outlet  the  source  of  supply  will  be  shut  off,  and 
thus  the  patient  is  spared  the  danger  and  discomfort  of  discharg- 
ing sinuses,  that  so  often  persist  after  early  operation. 

The  so-called  radical  treatment  of  the  abscess  of  spinal  disease 
is  unsatisfactory,  not  because  this  is  different  in  character  from 
other  tuberculous  abscesses,  but  because  it  is,  as  a  rule,  impossible 
to  remove  the  disease  of  which  the  abscess  is  a  symptom ;  and 
incomplete  or  ineffective  surgical  operations  should  be  avoided. 

As  the  abscess  is  a  symptom  of  disease,  so,  as  a  rule,  its 
treatment  should  be  symptomatic.  The  retrophcuryngeal  abscess 
demands  prompt  evacuation,  because  it  is  likely  to  obstruct 
breathing  and  swallowing,  because  its  sudden  rupture  may  cause 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  109 

death,  and  because  an  abscess  in  such  close  proximity  to  the  vital 
centres  is  always  a  source  of  danger.  In  cases  of  emergency  the 
abscess  may  be  evacuated  by  an  incision  in  the  middle  line  of  the 
pharynx,  but  preferably  the  opening  should  be  from  the  exterior. 
An  incision  is  made  along  the  posterior  aspect  of  the  sternomas- 
toid  muscle  in  its  upper  third.  The  abscess  tumor  is  easily 
reached  by  careful  dissection,  and  drainage  is  established  which 
has  evident  advantages  over  that  into  the  throat. 

Abscesses  from  the  middle  cervical  region  usually  point  in  the 
lateral  region  of  the  neck  and  cause  but  little  inconvenience. 
Abscesses  in  the  upper  thoracic  region  may,  in  rare  instances, 
cause  dangerous  pressure  on  the  trachea  or  lungs,  as  shown  by 
spasmodic  attacks  of  inspiratory  dyspnoea,  "  asthmatic  attacks." 
In  some  instances  an  area  of  dulness  near  the  seat  of  disease 
demonstrates  the  position  of  the  abscess,  but  if  it  lies  in  the 
median  line  it  cannot  be  detected  either  by  auscultation  or  percus- 
sion. If  the  inspiratory  dyspnoea  is  well  marked  the  symptom 
may  be  fairly  attributed  to  this  cause,  and  if  the  spasmodic 
attacks  are  frequent  and  severe  the  operation  of  costotransversectomy 
is  indicated.  An  incision  is  made,  preferably  on  the  right  side, 
to  expose  the  articulation  between  the  transverse  process  and  the 
rib,  and  one  or  more  of  the  joints  are  resected ;  the  finger  is  then 
inserted  and  passed  along  the  surface  of  the  adjacent  vertebral 
body  until  the  abscess  sac  is  reached.  This  is  usually  directly  in 
front  of  the  spine  at  or  about  the  fifth  dorsal  vertebra.  After 
incision  a  large  drainage-tube  should  be  inserted  (Fig.  9). 

In  the  lower  region  of  the  spine  intervention  may  be  necessary 
because  there  is  evidence  of  secondary  infection.  In  this  event  if 
the  abscess  distends  the  lumbar  region  or  forms  a  sac  on  either 
side  of  the  spine,  an  opening  in  the  loin  on  one  or  both  sides  of 
the  spine  is  necessary.  This  is  made  as  in  operations  on  the 
kidney,  by  an  incision  on  the  outer  side  of  the  erector  spinse 
muscle  between  the  last  rib  and  the  crest  of  the  ilium.  In  cer- 
tain cases  it  is  possible  to  expose  the  spine  and  to  remove  frag- 
ments of  necrosed  bone  along  with  the  contents  of  the  abscess. 
As  a  rule,  the  complete  removal  of  the  lining  membrane  of  the 
abscess  is  not  practicable,  and  one  must  be  content  to  evacuate 
the  solid  and  semi-solid  contents  by  flushing  with  hot  water, 
together  with  as  much  of  the  abscess  membrane  as  may  be 
removed  by  swabbing  with  gauze.  The  most  important  point  in 
the  operation  is  to  provide  efficient  and  complete  drainage  of  the 
cavity.     Two   or  more   counter-openings   are   usually   necessary 


110  OB  THOPEDIC  SUE  GEE  Y. 

when  the  kimbar  incision  has  been  made,  one  just  in  front  of  the 
anterior  superior  spine  and  another  in  the  thigh,  if  the  abscess  is 
of  the  psoas  variety.  Long  drainage-tubes  are  inserted,  and 
should  remain  until  a  proper  channel  for  the  escape  of  pus  has 
been  established. 

When  the  abscess  is  of  one  side  only,  not  extending  into  the 
thigh,  and  when  the  symptoms  do  not  indicate  infection,  but 
when  its  evacuation  seems  advisable  because  of  its  size  and  ten- 
sion, it  may  be  opened  by  an  anterior  incision  below  Poupart's 
ligament  just  to  the  inner  side  of  the  sartorius  muscle.  After 
copious  injections  of  hot  water  a  drainage-tube  may  be  inserted 
long  enough  to  reach  to  the  seat  of  disease  if  it  be  of  the  lumbar 
region. 

In  after-treatment  irrigation  is  not  often  required  ;  the  dressing 
should  be  of  dry  sterile  gauze,  and  great  attention  should  be  paid 
to  absolute  cleanliness  and  to  effective  drainage.  As  soon  as  is 
possible,  if  the  discharge  has  become  slight  and  if  the  spine  can 
be  properly  supported,  the  patient  is  allowed  to  walk  about  and 
to  go  into  the  open  air.  In  ordinary  cases  a  slight  discharge 
will  persist  for  several  months  or  longer,  depending  on  the  con- 
dition of  the  disease ;  if,  however,  it  be  quiescent  or  cured  the 
sinus  will  close  promptly. 

In  the  symptomatic  treatment  of  abscess,  aspiration  is  some- 
times of  service,  for  by  this  means  it  may  be  prevented  from 
increasing  in  size;  and  if  the  disease  is  quiescent,  the  cure  of  the 
abscess  may  follow  the  removal  of  its  contents  which  allows  the 
collapse  of  its  walls.  When  aspiration  is  employed  it  should  be 
repeated  systematically  as  often  as  the  abscess  cavity  refills. 
After  each  evacuation  pressure  should  be  applied  to  favor  the 
adhesion  of  the  apposed  walls. 

When  the  contents  are  of  such  a  nature  that  aspiration  is 
ineffective,  an  incision  may  be  made,  through  which  the  semi- 
solid substance  may  be  removed  by  vigorous  flushing  with  hot 
water.  The  opening  is  then  closed  by  several  layers  of  sutures, 
and  pressure  is  applied  with  the  aim  of  obtaining  primary  union. 
This  method  is  sometimes  successful,  but  usually  a  sinus  forms 
later  at  the  point  of  incision. 

Until  recently  the  injection  of  antituberculous  remedies  into  the 
abscess  sac  was  in  favor.  This  is  probably  of  value  in  diminish- 
ing the  infective  quality  of  the  contents,  perhaps,  also,  in  les- 
sening the  danger  of  mixed  infection  and  in  stimulating  the 
reparative  processes.     Clinically,  it  appears  to  have  little  direct 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  m 

effect  upon  the  course  of  the  tuberculous  disease.  An  emulsion 
of  iodoform  in  sterilized  oil  or  glycerin  (10  to  20  per  cent.),  in 
doses  of  from  4  to  30  grammes,  is  injected  at  intervals  of  from 
two  to  four  weeks,  with  or  without  previous  evacuation  of  the 
contents  ;  the  amount  and  the  frequency  of  the  injection  depend- 
ing upon  the  age  of  the  patient  and  upon  the  effect  of  the  treat- 
ment. If  used  with  caution  as  to  asepsis,  and  to  the  toleration  of 
the  patient  for  iodoform,  uo  harm  will  follow,  even  if  the  treat- 
ment proves  to  be  of  little  practical  value. 

When  an  abscess  approaches  the  surface  the  skin  becomes  red 
and  thin,  and  there  is  usually  some  local  tenderness  and  pain. 
Whenever  spontaneous  evacuation  of  the  abscess  is  probable  the 
mother  should  be  instructed  as  to  the  necessity  of  absolute  cleanli- 
ness, and  the  proper  dressings  should  be  provided.  After  the 
abscess  has  broken  the  patient  should  remain  in  bed  for  several 
days,  or  until  the  discharge  has  become  small  in  amount. 

In  the  symptomatic  treatment  of  the  abscesses  of  Pott's  disease 
one  may  conclude,  then,  that  operation  will  be  indicated  in  the 
treatment  of  the  retropharyngeal  abscess  and  in  the  rare  instances 
when  dangerous  pressure  is  exerted  by  an  abscess  in  the  posterior 
mediastinum.  It  is  indicated,  of  course,  when  there  is  evidence 
of  mixed  infection  or  when  the  rapidly  increasing  abscess  causes 
discomfort  or  interferes  with  effective  support.  It  is  usually 
indicated  when  the  abscess  is  of  large  size  if  proper  care  can  be 
provided.  The  operative  treatment  is  practically  free  from 
danger  if  cleanliness  and  efficient  drainage  can  be  assured. 
Aspiration  is  free  from  danger ;  it  is  often  of  service  in  prevent- 
ing the  enlargement  of  the  abscess,  and  it  may  hasten  its  absorp- 
tion. An  incision  which  allows  for  the  evacuation  of  the  solid 
material,  followed  by  immediate  closure  of  the  wound,  is  in  many 
instances  the  operation  of  selection. 

Paralysis  from  Pott's  Disease. 

The  tuberculous  process  in  the  vetebral  bodies  may  extend 
backward,  and  breaking  through  the  posterior  ligament  it  may 
enter  the  epidural  space  and  press  upon  the  spinal  cord ;  then 
follows  paresis  or  paralysis  of  the  parts  below  the  constriction. 

The  calibre  of  the  spinal  canal  is  not  usually  lessened  by  the 
characteristic  angular  distortion  of  the  back,  although  the  weight 
and  forward  inclination  of  the  trunk  may  force  the  softened 
tissues  backward  against  the  cord  and  thus  increase  the  direct 


112  ORTHOPEDIC  S  UB QEB  Y. 

pressure  ;  in  fact,  paralysis  is  much  more  often  associated  with 
a  slight  or  moderate  kyphosis  than  with  extreme  deformity. 

In  rare  instances  the  pressure  may  be  due  to  a  fragment  of 
necrosed  bone  or  to  solidification  of  the  tissues  in  and  about  the 
canal  during  the  process  of  repair.  It  may  be  caused,  in  part, 
at  least,  by  the  pressure  of  a  neighboring  abscess,  but  it  is 
usually  the  result  of  the  slow  advance  of  the  tuberculous  granu- 
lation tissue.  When  this  has  forced  an  entrance  into  the  spinal 
canal  it  sets  up  a  resistant  inflammatory  thickening  of  the  cover- 
ings of  the  cord,  first  a  peripachymeningitis  and  then  a  pachy- 
meningitis. In  addition  to  the  direct  pressure,  there  may  be  an 
interference  with  the  blood  supply  and  the  lymphatic  circulation, 
with  resulting  local  oedema  of  the  cord.  An  increase  in  the 
interstitial  connective  tissue  of  its  substance  and  a  corresponding 
atrophy  of  the  nervous  elements  may  follow,  and  as  a  sequence 
an  ascending  and  descending  degeneration  that,  in  prolonged 
cases,  may  terminate  in  partial  or  complete  sclerosis.  The  dura 
mater  is  a  resistant  structure,  and  direct  destruction  of  the  cord 
by  the  tuberculous  disease  is  rare.  In  fact,  as  a  rule,  but  little 
permanent  damage  results,  even  from  long-continued  pressure 
and  paralysis,  for  the  cord  seems  in  these  cases  to  possess  the 
power  of  repair  and  regeneration  to  a  remarkable  degree. 

Frequency.  In  1670  cases  of  Pott's  disease  recorded  at  the 
New  York  Orthopedic  Dispensary,  paralysis  occurred  in  218,^ 
and  in  445  cases  in  the  private  practice  of  Dr.  C.  F.  Taylor^  59 
cases  of  paralysis  were  observed.  Thus,  in  a  total  of  2015  cases 
of  Pott's  disease  there  were  279  cases  of  paralysis,  or  13.7  per 
cent. 

This  proportion  is  much  larger  than  the  normal,  hoAvever,  for 
many  of  the  patients  were  taken  to  the  specialist  or  to  the  special 
hospital  because  of  the  paralysis,  as  in  40  of  Taylor's  and  in  133 
of  the  dispensary  cases.  If  these  be  excluded,  the  percentage 
of  paralysis  occurring  in  those  actually  under  treatment  is  reduced 
to  5.6  per  cent.  This  percentage  corresponds  very  closely  to 
that  of  Dollinger,^  viz.  :  41  cases  of  paralysis  in  700  cases  of 
Pott's  disease  under  treatment  (5.8  per  cent.),  and  it  may  be 
accepted  as  representing  the  average  liability  to  paralysis  among 
those  who  have  received  treatment  for  Pott's  disease,  the  per- 
centage being  much  higher  in  neglected  cases. 

1  Myers.    Transactions  American  Orthopedic  Association,  1891,  Tol.  iii.  p.  209. 
s  Taylor  and  Lovett.    New  York  Medical  Record,  June  19,  1896. 
3  Loc.  cit. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  113 

The  Liability  to  Paralysis  in  Disease  of  the  Different  Regions  of 
the  Spine.  The  liability  to  paralysis  is  very  much  greater  in  dis- 
ease of  certain  regions  of  the  spine  than  in  others. 

Thus,  105  of  the  209  cases  in  Myers'  list,  in  which  the  situa- 
tion of  the  disease  was  recorded,  complicated  disease  of  the  dorsal 
region  above  the  eighth  vertebra.  Of  the  remainder,  in  16  the 
disease  was  of  the  cervical  region  ;  in  1 2  of  the  cervicodorsal,  and 
in  59  of  the  lower  dorsal  and  dorsolumbar  regions. 

Thirty-seven  of  Taylor's  59  cases  were  caused  by  disease  of  the 
dorsal  region ;  8  occurred  in  the  cervical  and  cervicodorsal,  and 
11  in  the  dorsolumbar  and  lumbar  regions. 

Twenty-six  of  the  total  of  41  cases  recorded  by  Dollinger  were 
caused  by  disease  of  the  third  to  the  seventh  dorsal  vertebrae, 
inclusive,  or  about  23  per  cent,  of  the  cases  in  which  this  region 
was  involved. 

Fig.  67. 


Pott's  paraplegia  before  the  stage  of  deformity.    The  apparatus  used  in  the  treatment 
of  this  case  is  shown  in  Fig.  51. 

Of  132  cases  of  paraplegia  reported  by  Gibney^  not  one  com- 
plicated disease  of  the  lumbar  region ;  nearly  all  were  caused  by 
compression  in  the  middle  or  upper  dorsal  segment. 

These  statistics  show  that  the  upper  and  middle  dorsal  section 
is  the  point  of  greatest  liability  to  paralysis — a  fact  that  is 
explained  po.ssibly  by  the  smaller  size  of  the  canal  at  this  point, 
and  by  the  difficulty  in  assuring  complete  fixation  at  the  seat  of 
disease.  It  may  be  estimated  that  in  15  per  cent,  of  the  cases 
of  Pott's  disease  of  this  region  paralysis  will  appear  before  cure 
is  established. 

Time  of  Onset.  In  exceptional  cases  the  paralysis  may  pre- 
cede deformity,  and  it  may  be  the  first  symptom  that  attracts 

'  Journal  of  Nervous  and  Mental  Disease,  January  ,5,  1897. 


114  ORTHOPEDIC  SURGERY. 

attention  to  the  disease.  In  14  of  74  cases  reported  by  Gibney 
the  paralysis  was  present  when  the  bone  disease  was  recognized, 
but  it  is  probable  that  the  primary  disease  had  existed  for 
several  months  before  the  appearance  of  the  paralysis.  Usually 
it  is  a  comparatively  late  symptom,  appearing  after  the  stage  of 
deformity  and  more  often  from  six  to  twelve  months  after  the 
recognition  of  the  disease,  but  its  appearance  may  be  deferred 
until  long  after  apparent  cure. 

Duration.  In  exceptional  cases  the  paralysis  ajjpears  to  be 
caused  simply  by  disturbance  of  the  circulation  of  the  cord,  due 
possibly  to  the  pressure  of  the  superincumbent  weight  upon  the 
softened  and  diseased  tissues,  as  it  disappears  almost  immediately 
when  the  sjiine  is  straightened  and  supported.  Usually  the 
paralysis  persists  for  several  months,  not  infrequently  it  lasts  a 
year,  and  partial  or  even  complete  recovery  is  possible  after  a 
much  longer  time.  Recovery  from  the  paralysis  depends  upon 
the  course  of  the  disease  of  which  it  is  a  symptom,  upon  the 
absorption  and  organization  of  the  tuberculous  granulations  that 
press  upon  the  cord,  and  upon  the  regenerative  changes  in  its 
structure,  if  it  has  been  implicated  in  the  disease. 

Symptoms  of  Pott's  Paraplegia.  The  most  marked  effect  of 
the  pressure  on  the  cord  is  the  interference  with  its  conductivity ; 
thus,  the  reflex  centres  situated  below  the  point  of  constriction, 
relieved  from  the  inhibition  of  the  brain,  become  overactive,  while 
voluntary  motion  of  the  parts  below  the  constriction  is  difficult 
or  impossible.  The  pressure  of  the  diseased  products  is  more 
directly  upon  the  anterolateral  columns,  so  that  motion  is  much 
more  often  primarily  affected  than  is  sensation. 

The  early  symptoms  of  Pott's  paraplegia,  as  noticed  by  the 
patient  or  his  friends,  are  weakness,  awkwardness,  and  a  stum- 
bling, shambling  gait.  The  symptoms  usually  increase  rapidly 
until  paralysis  of  motion  is  complete.  At  this  stage  the  patella 
tendon  reflex  is  increased,  and  ankle-clonus  is  often  present.  As 
a  rule,  both  limbs  are  affected  in  equal  degree,  but  occasionally 
paralysis  of  one  may  precede  that  of  the  other,  and  in  the  stage 
of  recovery  power  may  return  more  rapidly  on  one  side  than  on 
the  other.  The  limbs  in  the  early  stage  of  the  paralysis  may 
appear  limp  and  powerless,  but  when  the  patient  is  moved  or 
when  the  reflexes  are  stimulated  the  peculiar  spastic  rigidity  or 
stiffness  appears. 

As  a  rule,  the  stiffness  increases  with  the  duration  of  the  dis- 
ease, and  spastic  contractions  are  often  present ;  thus,  the  thighs 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  115 

may  be  approximated,  the  knees  flexed,  and  the  feet  extended. 
Persistent  contractions  indicate,  as  a  rule,  permanent  damage  to 
the  cord,  and  in  such  cases  complete  recovery  is  infrequent. 

Sensation  is  not  affected  ordinarily,  but  in  the  more  severe  or 
prolonged  cases  it  may  be  impaired  or  lost.  Sensation  was 
retained  throughout  in  24  of  the  40  cases  reported  by  Shaffer. 

In  the  cases  of  partial  paralysis  control  of  the  bladder  may  be 
retained,  but  usually  there  is  incontinence.  As  the  bladder  fills 
the  reflex  centre  is  excited,  and  it  empties  itself.  The  control  of 
the  sphincter  ani  is  less  often  or  less  noticeably  affected. 

As  the  paralysis  is  the  result  in  many  instances  of  active  or  of 
advancing  disease,  its  onset  may  be  preceded  by  discomfort  or 
pain.  Thus,  noticeable  discomfort  attended  by  an  exaggeration 
of  the  patella  tendon  reflex  may  be  considered  as  an  indication 
for  enforced  rest  of  the  individual,  although  increased  activity  of 
the  reflexes  is  not  uncommon  during  the  more  active  stage  of  the 
disease  without  apparent  involvement  of  the  spinal  cord.  When 
paralysis  occurs  in  patients  who  are  under  treatment  for  Pott's 
disease  the  onset  is  not  attended,  as  a  rule,  by  noticeable  or 
unusual  pain ;  nor  is  pain  usually  complained  of  after  the  paralysis 
has  developed. 

The  extent  of  the  paralysis  depends  upon  the  situation  of  the 
disease.  In  exceptional  cases,  in  which  the  cervical  cord  is  im- 
plicated, both  the  arms  and  legs  may  be  paralyzed  ;  this  occurred 
in  seven  of  the  cases  reported  by  Myers.  As  a  rule,  however, 
the  paralysis  is  a  complication  of  disease  of  the  dorsal  region, 
above  the  reflex  centres  in  the  lumbar  enlargement  of  the  cord, 
but  below  the  nerve  supply  of  the  upper  extremities.  If  the 
disease  were  at  a  lower  point,  for  example,  in  the  dorsolumbar 
section,  so  that  these  reflex  centres  themselves  were  directly  im- 
plicated, then  reflex  activity  would  not  be  increased,  and  inter- 
mittent incontinence  would  be  replaced  by  constant  dribbling  of 
urine.  If  the  cauda  equina  alone  were  implicated  in  disease  of 
the  lumbosacral  region,  the  symptoms  would  be  those  of  neuritis, 
pain,  numbness,  and  weakness  in  the  area  supplied  by  the  affected 
nerves.  Such  weakness  may  be  present  in  the  upper  extremities 
when  the  disease  is  in  the  neighborhood  of  the  origin  of  the 
brachial  plexus,  while  in  the  lower  limbs  the  characteristic  spastic 
condition  is  evident. 

The  nutrition  of  the  limbs  is  not  as  a  rule  greatly  affected, 
nor  do  the  contractions  become  permanent ;  but  when  the  par- 
alysis is  prolonged,  and  when  sensation  is  lost,  the  muscles  waste. 


116  OB  THOPEDIC  8  UB  GEB  Y. 

the  circulatiou  is  impaired,  and  fixed  distortions  usually  appear. 
Even  in  the  more  prolonged  and  severe  forms  of  paralysis, 
occurring  in  childhood,  bedsores  are  rarely  seen. 

Progfnosis.  In  properly  treated  cases  the  prognosis  is  very 
favorable,  as  is  illustrated  by  the  final  results  of  47  of  the  59 
cases  of  paraplegia  in  Taylor's  practice.  Of  these  39  recovered 
completely,  5  died  of  intercurrent  disease  while  apparently  recov- 
ering, and  in  3  the  recovery  was  partial. 

Of  the  hospital  cases  recorded  by  Myers,  3  per  cent,  died  of 
intercurrent  disease.  The  final  results  could  be  ascertained  in 
but  55  per  cent,  of  the  patients  who  remained  under  treatment. 
All  of  these  recovered. 

Of  74  cases  of  paraplegia  treated  by  Gibney^  45  were  cured, 
12  improved,  8  unimproved,  and  9  died.  Thus,  77  per  cent, 
were  cured  or  improved.  In  a  similar  series  of  40  cases  reported 
by  Shaffer  80  per  cent,  were  cured  and  but  10  per  cent,  of  the 
remainder  were  considered  as  hopeless  cases. 

In  a  total  of  975  cases  '^  abandoned  to  medical  treatment" 
collected  from  various  sources  by  Rozoy,^  there  were  429  cures. 
Of  the  remainder  16  were  improved;  130  were  unimproved,  and 
there  were  244  deaths.  The  contrast  in  the  results  reported 
would  appear  to  show  the  advantage  of  thorough  mechanical 
treatment. 

Recurrence  of  paralysis  after  recovery  is  not  infrequent;  in 
18  cases  such  recurrences  from  one  to  four  times  are  recorded  by 
Myers,  and  seven  successive  attacks  of  paralysis  were  observed 
in  a  patient  under  treatment  at  the  Hospital  for  Ruptured  and 
Crippled. 

The  relapses  are  due  apparently  to  the  renewed  activity  of 
the  disease,  and  in  many  instances  this  may  be  explained  by  the 
neglect  of  protective  treatment. 

Treatment.  The  treatment  of  the  paralysis  is  included  in  the 
treatment  of  the  disease  of  which  it  is  a  symptom,  except  that 
even  greater  care  should  be  exercised  to  assure  fixation  of  the 
spine. 

Rest  in  the  position  of  hyperextension  on  the  stretcher  frame 
is  indicated.  Direct  traction  by  the  weight  and  pulley  should 
be  used  if  the  disease  is  in  the  upper  dorsal  or  cervical  regions. 
For  bedridden  patients  a  convenient  method  of  assuring  extension 
of  the  spine  in  connection  with  head  traction  is  to  suspend  the 
trunk  on  a  sling  of  canvas  drawn  transversely  beneath  the  seat 

1  Loc,  eit.  -  Mai.  de  Pott,  Paris,  1901. 


TUBEBCULOUS  DISEASE  OF  THE  SPINE.  117 

of  disease  and  attached  to  bars  on  the  sides  of  the  bed  after  the 
Rauchfuss  method.  The  back  brace  or  the  plaster  jacket  assures 
additional  fixation,  and  such  support  should  be  employed  when- 
ever practicable.  If,  however,  the  brace  has  been  worn  as  an 
ambulatory  support,  its  shape  must  be  modified  to  accommodate 
the  change  in  the  outline  of  the  spine,  induced  by  recumbency 
and  extension. 

Manipulation  or  massage  of  the  limbs  is  contraindicated  because 
it  stimulates  the  reflex  centres.  If  constant  contractions  of  the 
muscles  are  present,  the  deformity  may  be  reduced  by  traction 
applied  in  the  ordinary  manner  (Fig.  32),  or  a  fixation  brace  may 
be  worn.  The  spasmodic  contractions  are  often  painful,  and  if 
the  paralysis  is  complicated  by  tuberculous  joint  disease,  extension 
and  fixation  combined  may  be  indicated  to  relieve  the  joint  from 
the  injury  of  involuntary  motion. 

Counterirritatiou  at  the  seat  of  disease  was  by  Pott  considered 
of  the  greatest  value,  and  the  application  of  the  actual  cautery 
from  time  to  time,  about  the  kyphosis,  seems  in  certain  cases  to 
exert  a  favorable  influence  on  the  underlying  disease. 

Electricity,  particularly  galvanism,  has  been  used,  and  it  is  of 
some  service  in  preserving  the  nutrition  of  the  limbs.  Its  value 
in  a  case  must  be  judged  by  its  effect. 

Of  the  internal  remedies  the  most  useful  seems  to  be  iodide  of 
potassium.  It  is  supposed  to  act  upon  the  tuberculous  granula- 
tion tissue  as  upon  the  products  of  syphilitic  disease.  A  conve- 
nient method  of  administration  is  a  solution  of  which  one  drop 
represents  one  grain  of  the  drug.  This  is  given  in  milk  or  in 
Vichy  water,  beginning  with  five  drops  three  times  daily  and 
increasing  the  dose  a  drop  each  day  until  the  point  of  toleration 
is  reached. 

The  first  indication  of  improvement  is  usually  lessening  of  the 
muscular  rigidity  ;  then  the  ability  to  move  a  toe  may  be  regained, 
after  which  recovery  follows  quickly.  At  this  stage  massage  of 
the  limbs  may  be  employed  with  advantage.  The  exaggerated 
reflexes  may  persist  long  after  recovery  ;  in  fact,  as  has  been 
stated,  this  symptom  is  not  uncommon  among  patients  suffering 
from  dorsal  Pott's  disease  who  have  never  been  paralyzed. 

The  Operative  Treatment.  The  operation  of  laminectomy  was 
at  one  time  in  favor,  but  it  has  now  been  practically  abandoned, 
as  a  treatment  of  routine  at  least,  for  the  paraplegia  of  Pott's 
disease ;  because  it  has  been  ])roved  that  recovery,  if  somewhat 
long  deferred,  is   the   rule   without  operation,  while  the   direct 


118  OB THOPEDIC  SURGE R  Y. 

death-rate  of  the  operation  is  a  large  one.  In  134  cases  collected 
by  Rhein^  the  immediate  mortality  (those  dying  within  a  month 
after  the  operation)  was  36  per  cent. 

Lloyd^  has  collected  128  '^  reliable"  cases  of  Pott's  disease  in 
which  laminectomy  was  performed.  The  deaths  due  directly  to 
the  operation  were  21  (16.45  per  cent.) ;  subsequent  deaths,  36 
(28.20  per  cent.) ;  total  deaths,  57  (44.55  per  cent);  recoveries, 
37  (28  per  cent.);  improved,  16  (12.5  per  cent.);  unimproved, 
18  (14.06  per  cent.). 

Laminectomy  is  an  incomplete  operation  in  the  sense  that  the 
disease  of  the  bone  is  not  removed,  and  recurrence  of  paralysis 
and  extension  of  the  disease  are  not  infrequent  after  a  successful 
immediate  result.  It  should  be  reserved  for  those  cases  in  which 
after  a  thorough  and  prolonged  trial  of  ordinary  methods  the  con- 
dition does  not  improve.  Eighteen  months  has  been  suggested 
as  the  proper  time  in  which  to  test  conservative  treatment.  The 
operation  may  be  indicated  also  if  the  symptoms,  in  spite  of  treat- 
ment, increase  in  severity,  and  when  there  is  evidence  that  the 
integrity  of  the  cord  is  threatened,  or  wlien  the  paralysis  is  of 
sudden  onset,  or  when  displacement  of  bone  or  pressure  from  an 
abscess  seems  probable  as  the  exciting  cause,  although  in  the 
latter  instance  the  direct  evacuation  of  the  abscess  by  costotrans- 
versectomy,  as  advocated  by  Menard,  should  precede  laminectomy. 
Occasionally  the  operation  is  indicated  as  a  forlorn  hope  in  adults 
suffering  from  cystitis  and  bedsores. 

The  usual  method  in  operating  is  as  follows :  A  long  incision 
is  made  parallel  to  and  close  by  the  side  of  the  spinous  processes. 
The  muscles  are  drawn  to  one  side,  the  spinous  processes  are  cut 
through  and  drawn  with  the  attached  muscles  to  the  opposite 
side.  The  laminae  at  the  seat  of  disease  are  then  removed  with 
the  cutting  forceps,  exposing  the  dura  mater.  The  tuberculous 
tissue  is  usually  found  upon  the  front  or  lateral  surfaces  of  the 
canal,  and  its  complete  removal  is  often  impossible.  The  shock 
of  the  operation  is  often  marked,  so  that  it  should  be  as  rapid  as 
possible,  and  loss  of  blood  should  be  carefully  guarded  against. 
As  a  rule,  the  wound  may  be  closed  without  drainage.  After  the 
operation  the  spine  should  be  supported  by  the  brace  or  jacket 
until  the  disease  is  cured. 

In  several  instances  forcible  correction  of  the  spine  (Calot's 
operation)  relieved  the  pressure  on  the  cord  and  rapid  recovery 

1  Willard.    Journal  of  Nervous  and  Mental  Disease,  May,  1897. 

2  Philadelphia  Medical  Journal,  February  22,  1902. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  119 

followed.  This  indicates  the  importance  of  assuring  overextension 
of  the  spine  whenever  it  is  possible,  but  this  should  be  attained 
preferably  by  gradual,  postural  correction  rather  than  by  force. 

Fortunately,  the  great  majority  of  cases  of  paraplegia  from 
Pott's  disease  occur  in  childhood,  and,  as  has  been  mentioned, 
the  complications  of  later  life,  bedsores,  cystitis,  and  the  like,  are 
rarely  troublesome.  Such  paralysis  in  the  adult  is  more  serious 
from  every  point  of  view.  The  principles  of  treatment  are  the 
same,  but  their  application  is  more  difficult  and  the  prognosis  is 
more  doubtful. 

Local  Paralysis.  In  certain  cases  the  extension  of  the  disease 
may  involve  the  nerve  roots  at  their  exit  from  the  spine.  This 
may  occur  with  or  independently  of  the  involvement  of  the  cord. 
The  symptoms  are  those  of  neuritis  in  the  affected  nerves.  In 
extremely  rare  instances  the  pressure  on  the  cord  may  cause 
hemiplegia. 

Forcible  Correction  of  the  Deformity  of  Pott's  Disease. 
Calot's  Operation.  Forcible  correction  of  the  deformities  of 
the  spine  was  advocated  by  several  of  the  ancient  writers,  notably 
by  Hijipocrates  and  by  Pare,  but  in  modern  times,  with  the  better 
understanding  of  the  pathology  of  Pott's  disease,  the  direct  de- 
formity that  a  patient  presented  when  coming  under  treatment 
was  supposed  to  be  irremediable,  since  it  represented  actual 
destruction  of  bone. 

In  1896  this  method  of  forcible  correction  of  deformity  which 
had  been  revived  by  Chipault  several  years  before^  was  popu- 
larized by  Calot,  of  Berck  sur  Mer,^  who  claimed  that  it  was  par- 
ticularly adapted  to  the  treatment  of  the  kyphosis  of  tuberculous 
disease.  Originally  he  advocated  the  immediate  correction  of 
such  deformity,  although  of  long  standing,  even  if  chiselling 
through  the  anchylosed  vertebrae  and  removal  of  the  spinous 
processes  were  required.  This  has  been  abandoned  long  since, 
and  even  the  treatment  to  be  described  has  fallen  into  practical 
disuse  at  least  in  this  country. 

At  the  Eleventh  Congress  of  French  Surgeons  at  Paris  in  1897 
Calot  outlined  the  operation  as  follows :  In  the  recent  cases  the 
deformity  was  corrected  by  direct  manual  traction  and  by  pressure 
on  the  kyphosis.  The  traction  employed  was  estimated  at  sixty 
to  one  hundred  and  sixty  pounds,  the  pressure  at  thirty  to  eighty 
pounds,  but  in  the  more  resistant  type  it  was  well  to  reduce  the 

1  Travaux  de  neurologie  Chir.,  1895, 1896, 1897. 

2  Archiv  prov.  de  Chir.,  February,  1897,  T.  6,  n.  2. 


1 20  OB  THOPEDIC  S  UB  GEB  Y. 

deformity  gradually  at  several  sittings.  Of  204  patients  treated 
by  this  raethod,  2  died  within  two  days  and  3  others  several 
months  after  the  operation.  In  1  case  partial  paralysis  appeared, 
and  in  another  an  abscess  appeared  soon  after  the  procedure. 

Since  Calot's  original  publication  hundreds  of  operations  have 
been  performed  with  results  not  differing  essentially  from  those 
that  he  reported.  It  has  been  demonstrated  that  the  deformity 
of  Pott's  disease  in  more  recent  cases  can  be  partly  or  entirely 
corrected  by  force  in  one  or  more  sittings  with  but  little  danger 
to  the  patient.^  If  the  disease  is  in  the  progressive  stage,  and  if 
the  operation  is  undertaken  before  adhesions  and  contractions 
have  formed,  the  correction  will  be  easy.  If  the  disease  is  in  the 
stage  of  repair,  the  correction  will  necessitate  forcible  separation 
of  contracted  tissues  and  the  breaking  up,  it  may  be,  of  an  actual 
anchylosis.  If  an  abscess  is  present,  whose  coverings  are  adher- 
ent to  the  surrounding  parts,  the  forcible  correction  may  rupture 
its  walls  and  allow  the  escape  of  the  pus  into  the  lung  or  pleural 
cavity.  The  more  remote  dangers  are  abscess  or  paralysis  due  to 
a  direct  extension  of  the  local  process,  or  general  dissemination 
of  the  tuberculous  disease. 

If  the  deformity  is  corrected  it  is  evident  that  there  must  be 
an  actual  separation  of  the  diseased  parts ;  the  spine  is,  as  it  were, 
straightened  on  the  hinge  formed  by  the  articulating  surfaces  of 
the  transverse  processes  (Fig.  4).  This  is  an  attitude  favorable  to 
repair,  since  compression  and  attrition  can  no  longer  aggravate  the 
destructive  process.  If  paralysis  is  present,  induced  in  part  by 
the  compression  of  the  softened  tissues  at  the  seat  of  disease,  it 
may  be  relieved  by  the  correction  of  the  deformity. 

It  must  be  borne  in  mind,  however,  that  the  operation  is 
undertaken  for  the  relief  of  deformity.  It  is  certain  that  the 
spine  can  be  straightened  and  that  it  can  be  retained  for  a  time  in 
the  corrected  position,  but  it  is  unlikely  that  the  interval  left 
between  the  upper  and  lower  segments  of  the  spine  will  be  filled 

1  Bradford  and  Cotton  (Boston  Med.  and  Surg.  Journ.,  September  20, 1900)  have  analyzed 
the  literature  of  Calot's  operation,  viz.  : 

Six  hundred  and  thirty-nine  corrections  were  performed  by  thirty-four  operators.  Time 
elapsed  varied  from  a  few  days  up  to  three  years  or  more.  Of  the  separate  detailed  cases  in 
7  more  than  one  year  had  elapsed :  in  35  more  than  six  months. 

Deaths  reported  from  all  causes,  25 ;  various  diseases,  5 ;  general  tuberculosis,  4  ;  trauma 
of  the  operation  and  chloroform,  5 ;  intercurrent  disease,  7. 

Immediate  results  :  Respiratory  embarrassment,  7  ;  pain,  6  ;  severe  shock,  3. 

Abscess  present  before  operation,  19  ;  ruptured,  4  ;  benefited  or  absorbed,  6  ;  appeared  after 
operation,  2. 

Paralysis  present  before  operation,  23  ;  relieved,  17  ;  not  relieved,  2  ;  made  worse,  1. 

Paralysis  appeared  after  correction  in  4. 

Direct  effect  on  deformity  in  224  cases :   Complete  correction,  130 ;  Incomplete,  94. 

Result  in  77  cases :   No  relapse,  20  ;  some  relapse,  50  ;  total  relapse,  7. 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  121 

with  new  bone,  because  the  capacity  for  bone  formation  is  in  this 
locality  very  feeble. 

There  is,  as  a  rule,  an  immediate  recurrence  of  a  certain  amount 
of  deformity  because  of  the  natural  recoil  toward  the  habitual 
posture,  and  because  in  many  instances  the  straightening  of  the 
spine  has  been  due  to  an  obliteration  of  secondary  curvatures 
rather  than  to  actual  separation  at  the  seat  of  disease.  Even  if 
the  deformity  were  obliterated,  and  if  the  interval  between  the 
segments  were  filled  with  calcified  tissue,  sucli  bone  cannot  grow ; 
consequently  the  irregularity  must  become  more  and  more  marked 
with  the  growth  of  the  child.  In  other  words,  although  the 
effect  of  the  destructive  disease  on  the  spine  may  be  modified  it 
cannot  be  entirely  remedied  even  by  the  most  successful  operation. 

The  Selection  of  Cases  for  Forcible  Correction.  The  favorable 
cases  are  those  in  which  the  deformity  is  of  comparatively  short 
duration,  cases  in  which  the  adhesions  and  the  accommodative 
changes  in  the  soft  parts  are  not  sufficient  to  offer  resistance  to 
correction,  and  in  which  the  internal  organs  have  not  been  long 
displaced  or  compressed.  Well-marked  deformities  of  the  middle 
and  lower  dorsal  region  are  especially  suitable  for  the  operation. 

The  most  unfavorable  cases  are  those  of  fixed  deformity,  in 
which  repair  is  progressing  or  is  completed,  and  in  which  the 
organs  and  tissues  of  the  body  have  been  changed  in  shape  and 
function  to  accommodate  the  new  conditions. 

As  a  rule,  deformity  of  the  lumbar  and  of  the  cervical  regions 
is  not  sufficient  to  require  forcible  correction. 

The  presence  of  an  abscess  in  the  posterior  mediastinum  or 
elsewhere,  if  it  be  in  the  active  or  progressive  stage,  should  con- 
traindicate  the  operation.  On  the  other  hand,  paralysis,  which 
is  most  often  a  complication  of  disease  in  the  dorsal  region,  is 
not  a  contraindication. 

The  Operation.  As  ordinarily  performed  the  patient  having 
been  prepared  as  for  the  application  of  a  plaster  jacket  is  anaes- 
thetized and  is  then  suspended  face  downward  in  the  horizontal 
position  by  five  assistants,  who  make  moderate  steady  traction 
upon  each  extremity  and  upon  the  head  while  the  surgeon,  stand- 
ing by  the  side  of  the  patient,  gently  presses  downward  directly 
upon  the  kyphosis,  which,  in  the  favorable  cases,  is  gradually 
obliterated,  the  straightening  of  the  spine  being  accompanied  by 
the  audible  separation  of  adhesions. 

As  a  rule,  the  force  required  is  much  less  than  that  stated  by 
Calot.     Jones  states  that  a  traction  force  of  nearly  six  hundred 


1 22  ORTHOPEDIC  S UR OER  Y. 

pounds  is  required  to  dislocate  the  neck  of  a  child  two  and  one- 
half  years  of  age  ;  that  five  men  pulling  in  the  manner  above 
described,  with  a  force  that  soon  tires,  rarely  exceed  a  traction 
farce  of  one  hundred  and  seventy-five  pounds. 

If  the  correction  is  to  be  completed  at  the  first  attempt  the 
spine  is  overextended,  and  while  it  is  held  in  this  attitude  a 
plaster  jacket  is  applied.  If  the  disease  is  of  the  middle  of  the 
back,  the  head  need  not  be  included,  but  it  is  better  to  fix  and 
draw  the  shoulders  backward  by  including  them  in  the  plaster. 
Great  care  should  be  taken  to  prevent  excoriations.  Very  long, 
thick,  wide  pads  should  be  placed  on  either  side  of  the  spinous 
processes ;  the  iliac  crests  and  other  prominences  should  be  pro- 
tected, and  a  so-called  dinner  pad  should  be  inserted  below  the 
sternum,  which  may,  when  removed,  allow  additional  room  for 
respiration.  This  is  of  great  importance  if  the  patient  has  not 
worn  a  plaster  jacket  before  the  operation.  If  the  disease  is  of 
the  upper  dorsal  region,  the  head  must  be  included  in  the  ban- 
dage. Calot  suspends  the  anaesthetized  patient  as  in  the  ordinary 
manner  for  applying  a  jacket ;  other  surgeons  suspend  the  patient 
with  the  head  downward  during  the  application  of  this  part  of 
the  bandage,  but  with  a  little  care  the  head  support  may  be 
applied  with  the  patient  in  the  horizontal  position. 

The  hair  should  be  cut  closely,  and  protected  from  the  plaster 
by  a  well-fitting  skull  cap.  The  bandage  is  then  continued  over 
the  head  and  neck  as  in  the  illustration  (Fig.  59).  A  strip  of 
malleable  steel,  bent  to  fit  the  occiput,  may  be  incorporated  in 
the  bandage  to  give  it  sufficient  strength. 

Many  surgeons  employ  other  supports  than  the  plaster.  One 
of  the  best  forms  of  apparatus  is  the  double  Thomas  brace  used 
by  Jones.  The  stretcher  frame  may  be  used  with  the  plaster 
jacket  to  assure  recumbency. 

In  properly  selected  cases  there  is  little  shock  after  the  opera- 
tion, but  if  the  change  in  the  contour  of  the  spine  has  been  con- 
siderable, respiration  may  be  somewhat  embarrassed  by  the 
plaster  jacket.  In  such  cases  it  must  be  split  through  the  front 
and  separated.  In  all  cases  it  is  well  to  cut  through  the  plaster 
at  points  where  direct  pressure  is  likely  to  be  exerted,  in  order 
to  guard  against  excoriations. 

As  a  rule,  the  operation  should  be  followed  by  prolonged  rest 
on  the  back,  three  to  six  months  or  longer,  to  allow  for  adapta- 
tion to  the  new  position  and  for  consolidation. 

As  has  been  stated,  there  is  a  marked  tendency  toward  recur- 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  123 

rence  of  deformity.  On  this  account,  some  surgeons  advocate 
wiring  the  spinous  processes  to  one  another  as  originally  sug- 
gested by  Hadra  and  practised  by  Chipault.  The  operation  is  a 
simple  one,  but  its  efficacy  is  more  than  doubtful. 

In  cases  in  which  the  deformity  is  of  the  resistant  type  it  is 
well  to  divide  the  rectification  into  several  sittings  at  intervals 
of  a  week  or  more.  In  many  instances  anaesthesia  is  not  required 
after  the  first  operation  ;  for  traction  and  even  the  forcible  press- 
ure at  the  seat  of  disease  do  not  appear  to  cause  particular  dis- 
comfort. 

Gradual  Correction  of  Deformity.  Corrective  force  may  be 
applied  also  by  methods  that  do  not  deserve  the  name  operation. 
For  example,  a  certain  amount  of  traction  and  pressure  may  be 
employed  with  advantage  during  the  application  of  the  plaster 
jacket  in  the  ordinary  manner  if  the  cases  are  properly  selected, 
and  the  effect  of  posture  in  correcting  deformity  is  illustrated  by 
the  use  of  the  stretcher  frame. 

An  efficacious  method  of  gradual  or  non-violent  correction  is 
that  employed  by  Goldthwait'  by  horizontal  traction  and  lever- 
age.    This  method  is  described  by  him  as  follows  : 

"  The  apparatus  which  has  been  used  consists  of  a  strong  gas- 
pipe  frame,  six  feet  long  by  two  feet  wide.  Suspended  from  this 
is  a  bar  (a),  in  the  centre  of  which  is  a  vertical  rod  (6),  forked  at 
the  top  and  long  enough  to  reach  to  the  level  of  the  frame.  This 
crossbar  is  simply  suspended  from  the  frame  so  that  its  position 
can  be  changed  as  desired.  Below  this  is  another  crossbar  (c), 
which  rests  on  the  frame  and  can  also  be  adjusted  as  to  position. 
Upon  this  latter  piece  (c)  and  upon  the  fork  of  the  rod  (6)  rest 
two  malleable  steel  bars  {d),  about  eighteen  inches  long.  These 
rest  in  grooves  one  inch  apart,  and  should  be  bent  to  partly  con- 
form with  the  lumbar  curve  of  the  spine,  after  which  they  are 
heavily  padded  with  felt  and  the  patient  laid  upon  them.  The 
upper  end  of  the  bars  (d)  should  just  rest  upon  the  fork,  not 
projecting  over,  and  when  the  patient  is  in  position  the  rod  should 
be  one  inch  above  the  apex  of  the  deformity.  The  buttocks  rest 
upon  the  crossbar  (c),  and  the  legs  are  supported  by  one  or  more 
heavy  webbing  straps  which  can  be  tightened  or  loosened  at  will. 
No  support  whatever  is  given  the  upper  part  of  the  body,  except 
that  the  head  is  steadied  by  the  surgeon  with  the  hand  until  a 
satisfactory  amount  of  correction  has  been  accomplished,  and  then 

Transactions  American  Orthopedic  Association,  vol.  xi.  p.  95. 


12i 


ORTHOPEDIC  SURGERY. 


a  strap  similar  to  those  used  below  gives  the  support  so  that  the 
operator's  hand  is  free.  If  traction  is  desirable,  it  can  be  applied 
by  means  of  a  ^^^ndlass,  which  is  attached  to  each  end  of  the 
frame.  This  makes  it  possible  to  obtain  much  more  definite  and 
steady  traction  than  would  be  possible  with  assistants,  but  its  use 
has  not  been  found  necessary  in  the  majority  of  the  cases,  simjjle 
overextension  of  the  spine  accomplishing  the  same  results. 

"  When  the  maximum  overextension  that  is  desirable  is  obtained, 
the  strap  under  the  head  is  fastened  and  the  patient  allowed  to 
lie  in  this  position  while  the  jacket  is  applied.  In  applying  this 
the  iliac  crests  should  be  generously  padded  with  heavy  felt,  and 
a  similar  pad  should  be  placed  over  the  upper  part  of  the  sternum, 


Fig.  68. 


The  plaster  jacket  applied  in  supine  posture  by  means  of  the  Metzger-Goldthwait  apparatus. 

SO  that  the  jacket  can  be  carried  high  up  to  prevent  the  upper 
part  of  the  body  with  the  shoulders  from  drooping  forward.  In 
the  cases  with  disease  in  the  upper  dorsal  region  the  jacket  should 
be  moulded  about  the  anterior  part  of  the  neck  .so  that  erect  posi- 
tion of  the  head  is  necessary.  The  forked  rod  (6)  is  easily 
avoided  by  a  few  figure-of-eight  turns  of  the  bandage,  so  that 
when  the  plaster  has  set  the  patient  can  easily  be  lifted  off,  and 
as  the  rod  (6)  should  be  placed  one  inch  above  the  apex  of  the 
deformity  this  weak  spot  in  the  jacket  is  not  objectionable. 

"  When  the  patient  is  taken  off  the  frame  the  two  rods  (c?)  are 
slipped  out  from  below,  leaving  the  padding  in  place. 

"As  a  matter  of  experience  it  has  been  found  necessary  to  prac- 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  125 

tically  always  cut  a  small  window  over  the  point  of  greatest 
deformity,  as  otherwise  when  the  body  settles  down,  as  is  inevi- 
table, a  slough  will  form  even  though  a  liberal  amount  of  padding 
has  been  used.  This  procedure  is  repeated  from  time  to  time 
until  tlie  best  possil^le  attitude  has  been  obtained." 

This  method,  originally  devised  as  a  modification  of  the  Calot 
method  of  forcible  correction  of  defomity,  is  now  employed  in 
the  routine  application  of  the  plaster  jacket.  For  this  purpose 
Goldthwait  uses  a  portable  frame,  as  shown  in  the  illustration 
(Fig.  69).    _ 

The  appliances  shown  on  page  89,  in  which  the  force  of  gravity 
is  utilized  to  straighten  the  spine,  are  now  more  commonly  used 
for  the  application  of  the  jacket  in  the  recumbent  posture. 

Fig.  69. 


Goldthwait's  portable  frame  for  applying  the  plaster  jacket. 

It  may  be  stated  of  forcible  correction  of  the  spine  (Calot's 
operation),  that  it  is  in  no  sense  curative  ;  that  although  it  has 
been  proved  that  the  back  can  be  straightened,  in  many  instances 
with  ease  and  in  most  cases  with  but  little  danger,  yet  the  reten- 
tion of  the  spine  in  the  corrected  position  is  difficult,  and  a  certain 
immediate  recoil  toward  deformity  is  the  rule.  Even  if  the 
interval  between  the  two  segments  be  filled  with  new  bone,  the 
growth  of  the  spine  at  this  point  being  checked,  an  increase  of 
the  irregularity  with  advancing  years  may  be  expected.  In  fact, 
correction  of  deformity  is  in  no  sense  a  substitute  for  preven- 
tion. 

The  operation  in  its  original  form  should  be  reserved,  in  the 
writer's  opinion,  for  cases  in  which  the  deformity  is  sharply 
angular,  showing  that  the  destructive  process  is  limited  in  its 
extent.     If  correction  is  attained,  horizontal  fixation  should  be 


126  ORTHOPEDIC  SURGERY. 

continued,  if  possible,  for  many  mouths  as  an  essential  part  of  the 
treatment. 

The  final  judgment  cannot  be  passed  upon  this  procedure  at 
the  present  time.  It  has  rapidly  lost  favor  recently,  partly 
because  of  recurrence  of  deformity,  and  partly  because  experience 
has  shown  that  the  same  degree  of  rectification  may  be  attained 
by  milder  methods. 

The  Duration  of  the  Treatment  of  Pott's  Disease.  The  duration 
of  the  treatment  must  depend  upon  the  extent  and  severity  of  the 
disease.  It  may  be  divided  into  two  periods :  one  during  which 
the  disease  is  active,  when  absolute  fixation  is  indicated,  and  a 
stage  of  recovery,  during  whicli  supervision  is  required.  During 
the  first  stage  the  destructive  process  may  increase  the  absolute 
deformity  ;  during  the  later  period  of  weakness  the  distortion 
may  increase,  simply  because  of  the  general  inclination  toward 
deformity  and  because  of  the  atrophy  of  the  supporting  muscles. 

Tuberculosis  of  the  spine  is  slow  in  its  progress,  and  recovery 
is  often  insecure.  The  course  of  the  disease  is  shortest  in  the 
cervical  region,  but  even  here  two  years  of  brace  treatment  will 
probably  be  required,  and  in  the  lower  region  double  this  time, 
even  in  the  milder  type  of  cases.  Active  treatment  should  be 
continued  as  long  as  there  is  evidence  of  disease.  The  absence 
of  actual  pain  and  discomfort  is  of  little  value  in  determining  the 
absolute  cure  if  braces  have  been  employed.  The  absence  of 
muscular  spasm  is  more  significant,  since  it  usually  persists  as 
long  as  the  disease  is  active.  The  presence  of  pain  on  passive 
motion  or  muscular  contraction  or  abscess  would,' of  course,  indi- 
cate the  necessity  of  further  treatment. 

Direct  palpation  is  of  some  value  in  determining  the  condition 
of  the  affected  part.  During  the  progressive  stage,  careful,  deep 
pressure  over  the  spinous  processes  may  show  greater  mobility  of 
those  involved  in  the  disease.  During  the  stage  of  repair  and 
consolidation  the  mobility  is  replaced  by  rigidity.  The  appear- 
ance of  the  kyphosis  has  some  significance.  In  the  early  stage  of 
the  disease  its  area  is  not  clearly  defined,  but  when  consolidation 
has  taken  place  its  extent  is  shown  by  the  rigid  vertebrae,  which 
stand  out  separated  from  the  remainder  of  the  spine  by  a  well- 
marked  sulcus,  which  is  much  deeper  below  than  above  the 
kyphosis. 

Even  when  the  disease  appears  to  be  cured,  removal  of  siqiport 
should  be  gradual  and  tentative  ;  the  jacket  should  be  replaced 
by  the  corset,  or  the  brace  by  a  lighter  appliance ;  then  support 


TUBERCULOUS  DISEASE  OF  THE  SPINE.  127 

may  be  removed  at  night,  later  for  part  of  the  day,  and  at  last, 
after  many  months,  it  may  be  discarded.  Then  may  follow 
massage  of  the  atrophied  muscles  of  the  trunk  and  gentle  exercise. 

Such  careful  supervision  must  be  continued  for  a  much  longer 
time  if  the  best  ultimate  result  is  to  be  attained,  for,  as  has  been 
mentioned,  one  should  guard  against  the  secondary  distortions, 
which  may  be  due  simply  to  weakness  and  to  the  unfavorable 
mechanical  conditions  induced  by  the  primary  deformity.  If 
curvatures  of  the  spine  are  so  common  among  those  whose  backs 
may  be  supposed  to  be  fairly  normal,  how  much  more  likely  is 
such  secondary  deformity  to  result  when  the  back  has  been  weak- 
ened by  disease  and  by  long  disuse  of  the  muscles. 

This  secondary  increase  of  deformity  is  not  so  much  to  be 
feared  after  the  cure  of  the  disease  in  the  lumbar  region,  because 
of  the  favorable  attitude  of  erectness,  nor  is  it  likely  to  be  marked 
after  cure  in  the  cervical  region  of  the  spine ;  but  in  disease  of 
the  upper  and  middle  dorsal  region  support  must  be  continued 
long  after  the  disease  is  cured,  and  supervision  must  be  exercised 
until  after  the  period  of  adolescence,  if  the  increase  of  deformity 
is  to  be  prevented. 

Recurrence  of  Disease  and  Later  Effects  of  Deformity. 
The  disease  may  recur  after  aa  interval  of  many  years  of  apparent 
cure,  and  such  recurrences  are  sometimes  accompanied  by  the 
formation  of  an  abscess  or  by  paralysis. 

If  recovery  from  Pott's  disease  has  been  complete,  and  if  de- 
formity has  been  prevented,  the  condition  of  the  patient  is  to  all 
intents  normal,  but  if  the  course  of  the  disease  has  been  prolonged 
and  if  the  deformity  is  great  his  condition  is  abnormal;  he  is 
unfitted  for  ordinary  occupations,  and  comparative  comfort  is 
assured  only  by  constant  care.  Such  individuals  are  likely  to 
suffer  from  neuralgic  pain  about  the  weakened  spine  on  overexer- 
tion or  whenever  the  general  condition  is  depressed  from  any 
cause.  In  such  cases  the  use  of  some  form  of  light  corset  adds 
to  the  comfort  of  the  patient. 

In  certain  instances  pain  localized  in  the  lateral  region  of  the 
trunk  may  be  caused  by  compression  of  an  intercostal  nerve,  or 
it  may  be  due  to  compression  of  the  tissues  between  the  last  rib 
and  the  chin.  In  several  cases  of  this  character,  reported  by 
Goldthwait,  resection  of  a  portion  of  a  rib  at  the  seat  of  pain 
relieved  the  discomfort. 

Secondary  Deformities,  While  the  patient  is  under  treatment 
for  Pott's  disease  one  should  be  on  the  alert  to  prevent  other 


128  ORTHOPEDIC  SURGERY. 

deformities  that  may  follow  the  general  weakness  and  restriction 
of  normal  functions.  One  of  these  is  the  iceak  foot,  sometimes 
called  weak  ankle  or  flat  foot,  and  with  it  is  often  associated  a 
moderate  degree  of  knock-knee.  This  may  be  prevented  by  the 
use  of  a  shoe  of  proper  shape,  of  which  the  heel  and  sole  are 
thickened  slightly  on  the  inner  side. 

Recapitulation.  Fixation  on  the  stretcher  frame  is  the  treat- 
ment of  choice  in  infancy  and  early  childhood,  without  regard  to 
the  situation  of  the  disease.  Ambulatory  treatment  is  the  treat- 
ment of  selection  in  later  childhood,  adolescence,  and  adult  life. 

Ambulatory  treatment  must  always  supplement  that  by  recum- 
bency, and  in  the  great  majority  of  cases  it  is  the  treatment  of 
necessity  and  routine.  Its  efficiency  will  depend,  in  great  meas- 
ure, upon  the  careful  regulation  of  the  strain  which  the  erect 
posture  and  the  activity  of  the  patient  throws  upon  the  weakened 
spine. 

Of  the  relative  merits  of  the  supports  that  have  been  described 
it  may  be  stated  that  the  plaster  jacket  has  the  great  advantage 
of  cheapness;  its  use  places  the  treatment  in  tlie  hands  of  the 
surgeon,  and  in  the  middle  region  of  the  spine  it  is  equal  to,  and 
may  even  be  superior  to,  the  brace.  The  laced  corset  is  not 
equal  as  a  support  to  the  solid  jacket. 

The  back  brace  has  a  wider  range  of  adaptability  than  the 
jacket.  Its  disadvantages  are  the  original  expense,  the  difficulty 
of  accurate  adjustment,  and  the  fact  that  it  can  be  removed  by 
the  parents,  who  are  inclined  to  neglect  medical  supervision, 
when  the  use  of  the  apparatus  has  become  familiar  to  them. 

The  jury  mast,  although  a  very  useful  appliance  under  certain 
circumstances,  is  inferior  to  the  metallic  head  rest  when  accurate 
fixation  or  support  is  desired. 

The  complications  of  Pott's  disease,  abscess  and  paralysis, 
should  be  considered  and  treated  as  symptoms  only — symptoms 
that  may  or  may  not  require  direct  treatment  according  to  the 
indications  that  have  been  described.  Finally,  one  should  always 
bear  in  mind  that  the  final  cure  of  the  disease  depends  upon  the 
increase  of  the  vital  force  ;  thus,  the  importance  of  fostering  and 
improving  the  general  well-being  of  the  patient  cannot  be  too 
strongly  urged. 


CHAPTER    II. 


NON-TUBERCULOUS  AFFECTIONS  OF   THE  SPINE. 


Fir  70 


znS 


Syphilis. 

Syphilis,  in  the  inherited  or  in  the  later  stages  of  the  acquired 
form,  may  affect  the  bones  of  the  spine  and  cause  local  deformity 
and  symptoms  that  cannot  be  distinguished  from  those  of  Pott's 
disease. 

Diagnosis.     As  compared  with  tuberculosis,  it  is  a  rare  disease 
of  the  spine.^     Its  manifestations  are  likely  to  be  general  in  char- 
acter,   the    deformity   of    the    spine 
being  but  one  of  many  evidences  of 
disease. 

If  syphilis  were  limited  to  the 
spine  and  simulated  the  symptoms 
and  the  deformity  of  Pott's  disease, 
it  ^  would    demand    the    same    local 

El 

treatment.  Specific  remedies  should 
■  ^^  be  administered  when  one  has  reason 
to  suspect  the  presence  of  the  syph- 
ilitic taint,  even  if  the  local  disease 
appears  to  be  tuberculous  in  charac- 
ter. 

^-   Malignant  Disease  of  the  Spine. 

Malignant  disease  of  the  spine  is 
a  rare  affection,  particularly  so  in 
childhood.  Sarcoma  is  more  com- 
mon than  carcinoma,  and  it  may 
affect  the  spine  primarily.      Carci- 

Vertical    anteroposterior    section   of  -        i  j.     i  ^  .^a, .,  *^ 

lumbarspine,  showing  deposit  of  gum-  noma  IS  almost  always  secondar>  to 
ma  in  the  posterior  part  of  the  third  and  ^  ^rimarv  tumor  elscwhere,  the  spine 

fourth  vertebr;e.    (After  Fournier.)  i  •'  i    i  • 

becoming  involved  by  metastasis  or 
by  contiguity.  Schlesinger,^  in  3720  cases  of  carcinoma,  found 
secondary  growths  in  the  spine  in  54. 


'  Jasinski.    Arcbiv  f.  Dermat.  u.  Syph.,  Bd.  xxiii.  S.  400. 
^  Buckley.    Journal  of  Nervous  and  Mental  Disease,  April,  1902. 
9 


130  ORTHOPEDIC  SUBOEBY. 

Diagnosis.  Malignant  disease  differs  from  tuberculosis  of  the 
spine  in  that  its  symptoms  are  usually  more  severe ;  the  pain  is 
usually  persistent,  and  it  is  not  relieved  by  support  or  recum- 
bency, as  is  that  of  Pott's  disease.  The  constitutional  symptoms 
are  more  marked,  and  the  steady  progress  of  the  disease  toward 
a  fatal  termination  is  soon  apparent.  Locally,  the  angular 
deformity  is  usually  slight,  and  it  may  be  absent.  Not  infre- 
quently the  tumor  may  be  palpated  through  the  abdominal  wall. 

Paralysis  is  a  frequent  and  often  an  early  symptom.  In  a 
case  of  melanotic  sarcoma  of  the  spine  in  a  boy  aged  twelve 
years,  seen  recently,  complete  paralysis  of  motion  and  sensation 
in  the  lower  extremities  preceded  noticeable  symptoms  pointing 
to  the  local  disease. 

As  has  been  stated,  carcinoma  is  almost  always  secondary  to 
disease  elsewhere ;  thus,  if  after  the  operation  for  the  removal  of 
carcinoma  symptoms  of  disease  of  the  spine  appear,  one  should 
suspect  this  complication. 

Malignant  disease  of  the  spine  is  a  fatal  affection,  and  the 
treatment  can  be  but  palliative. 

Acute  Osteomyelitis  of  the  Spine. 

Infectious  osteomyelitis  of  the  spine  is  comparatively  uncom- 
mon. The  lower  vertebrae  are  more  often  affected.  In  5  of  41 
cases  reported  by  EicheP  the  atlo-axoid  region  was  involved. 

Symptoms.  The  symptoms  are  similar  to  those  of  acute  infec- 
tious processes  elsewhere,  and  are  characterized  by  sudden  onset, 
with  pain,  fever,  and  constitutional,  depression.  There  is  local 
pain  and  tenderness  about  the  spine.  Abscess  quickly  forms ; 
and  paralysis  from  the  rapid  extension  of  the  disease  is  a  common 
complication.^  The  symptoms  due  to  pyogenic  infection  and  to 
deep-seated  abscess  are  often  pysemic  in  character,  and  necrosis 
of  the  affected  vertebral  bodies  may  result  in  the  formation  of 
large  sequestra. 

A  more  localized  and  more  chronic  form  of  osteomyelitis  may 
occur,  and  abscess  may  be  the  first  sign  of  the  disease.  In  all 
cases  of  this  character,  whether  acute  or  chronic,  other  bones  or 
joints  or  other  tissues  are  often  involved,  and  in  many  instances 
an  infected  wound  or  discharging  ear,  for  example,  may  indicate 
the  source  of  infection. 

1  Mlinch.  med.  Wochen.,  1900,  No.  35. 

-  Miiller.    Deutsche  Zeits.  f.  Chir.,  Bd.  xli. 


NON-TUBEBCULOUS  AFFECTIONS  OF  THE  SPINE.     131 

Treatment.  The  treatment  consists  in  the  immediate  evacua- 
tion and  drainage  of  the  abscess,  the  removal  of  the  necrosed 
bone  if  possible,  and  in  supporting  the  spine  during  the  subse- 
quent stage  of  weakness. 

Actinomycosis  of  the  Spine. 

Actinomycosis  of  the  spine  is  an  extremely  rare  disease,  and 
need  only  be  mentioned  as  a  possibility.  The  spine  was  involved 
secondarily  in  about  2  per  cent,  of  the  reported  cases.^  The  diag- 
nosis may  be  made  by  the  microscopic  examination  of  the  dis- 
charge from  the  sinuses  that  almost  always  form  when  bone  is 
affected. 

Injury  of  the  Spine. 

Severe  sprains  or  fractures  may  simulate  disease  very  closely 
and  in  some  instances,  particularly  injury  of  the  cervical  region, 
diagnosis  is  practically  impossible  until  after  treatment  by  sup- 
port and  fixation  has  been  applied,  when,  as  a  rule,  if  disease  be 
absent,  the  symptoms,  even  though  of  long  standing,  quickly 
subside. 

Fracture  of  the  spine  in  the  middle  region  may  result  in  angu- 
lar deformity ;  and  when  proper  support  has  been  neglected, 
symptoms  of  pain  and  weakness,  similar  to  those  of  Pott's  disease, 
may  persist  indefinitely. 

Sudden  forcible  compression  of  one  or  more  of  the  vertebral 
bodies  without  displacement  and  without  severe  immediate  symp- 
toms, other  than  the  slight  deformity,  may  be  the  result  of  injury, 
especially  falls  from  a  height.  These  cases  are  not  uncommon, 
and,  as  the  severity  of  the  injury  is  not  often  recognized,  the 
local  deformity,  which  may  not  attract  attention  until  several 
weeks  after  the  accident,  combined  with  stiffness  and  weakness, 
lead  to  the  mistaken  diagnosis  of  Pott's  disease. 

Rupture  of  spinal  ligaments  may  be  caused  by  forced  forward 
bending  of  the  spine.  The  resulting  deformity  and  weakness 
resemble  those  caused  by  a  crush  of  one  of  the  vertebral  bodies. 
A  number  of  cases  have  been  described  by  Painter  and  Osgood.^ 

1  Erving.    Johns  Hopkins  Bulletin,  November,  1902. 

2  Boston  Medical  and  Surgical  Journal,  January  2, 1902. 


132 


ORTHOPEDIC  SURGERY. 


Traumatic  Spondylitis. 

KummelP  has  described  a  form  of  rarefying  ostitis  of  the  spine 
of  non-tuberculous  origin,  apparently  caused  by  injury.  It  is 
characterized  by  symptoms  of  pain  and  weakness  referred  to  the 
back,  and  by  pronounced  rounded  kyphosis  of  the  dorsal  region. 
Motor  disturbances  of  the  lower  extremities  are  frequent. 


Fig.  71. 


Khachitic  kyphosis. 

Kummell's  cases  do  not  differ  particularly  from  those  of  injury 
that  have  been  described.  In  fact,  in  the  neglected  cases  of 
injury  of  the  spine  the  pain  and  weakness  may  persist  indefinitely, 
and  the  deformity  may  increase.  In  certain  instances  there  may 
be  a  secondary  infection,  tuberculous  or  otherwise,  at  the  seat  of 
injury,  and  in  others  the  injury  may  be  the  exciting  cause  of 
spondylitis  deformans,  but  such  results  are  unusual. 


1  Deutsche  med.  Wochen.,  1895,  No.  11. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     133 

Treatment.  In  all  such  cases,  and  whenever  weakness  of  the 
spine  persists,  and  when  motion  causes  pain,  a  support  should  be 
employed  as  in  the  treatment  of  Pott's  disease.  If  possible, 
deformity  if  of  recent  origin  should  be  corrected,  in  part  at 
least,  either  by  the  method  of  Calot  or  by  recumbency  before 
the  support  is  applied. 

The  Rhachitic  Spine. 

The  rhachitic  spine  has  been  described  in  the  consideration  of 
the  differential  diagnosis  of  Pott's  disease  (p.  50).  It  most  often 
develops  during  the  first  or  second  year  of  life,  in  children  who 
sit  the  greater  part  of  the  time ;  it  is,  in  fact,  simply  an  exag- 
geration of  the  contour  which  is  normal  in  the  sitting  posture. 
The  typical  rhachitic  kyphosis  is  thus  a  rounded  projection  of  the 
lower  region  of  the  spine,  which  is  more  or  less  rigid  according 
to  its  duration.  If  the  deformity  is  extreme  there  may  be  a  com- 
pensatory backward  inclination  of  the  head  which  may  be  accom- 
panied by  contraction  of  the  posterior  group  of  muscles,  ' '  cervical 
opisthotonos." 

Treatment.  Aside  from  the  constitutional  treatment  of  the 
rhachitic  condition,  and  from  the  measures  that  should  be  employed 
to  improve  the  nutrition  of  the  muscles  in  general,  the  indica- 
tions are  to  overcome  the  rigidity  and  the  limitation  of  motion  of 
the  spine ;  to  support  it,  if  necessary,  during  the  stage  of  weak- 
ness ;  and  to  remove,  if  possible,  the  predisposing  causes  of  the 
deformity. 

The  correction  of  the  deformity  may  be  accomplished  by 
massage,  and  by  direct  manipulation  of  the  spine.  The  child  is 
placed,  face  downward,  on  a  table ;  one  hand  is  applied  over  the 
projection,  and  with  the  other  the  legs  are  raised  to  throw  the 
spine  into  a  position  of  overextension.  This  stretching  is  per- 
formed slowly  and  carefully  over  and  over  again  at  morning  and 
night,  and  the  manipulation  is  followed  by  thorough  massage  of 
the  muscles.  If  the  deformity  is  marked  and  if  the  general 
rhachitic  process  is  still  active,  the  infant  may  be  kept  for  several 
months  in  the  recumbent  posture,  on  a  light  frame,  in  an  attitude 
of  overextension,  as  described  in  the  treatment  of  Pott's  disease. 

In  older  subjects  some  form  of  light  back  brace  may  be  suffi- 
cient in  connection  with  the  massage,  and  systematic  correction 
of  the  deformity. 

The  Natural  Cure.  It  may  be  stated  that  the  rhachitic  spine  is 
to  a  certain  extent  corrected   when  the  erect  posture  is  assumed. 


134  ORTHOPEDIC  SUBGEBY. 

by  the  inclination  of  the  pelvis  and  accompanying  lordosis.  This 
natural  cure  is,  however,  often  rather  a  distribution  of  deformity 
than  a  cure,  for  the  upper  part  of  the  projection  may  remain  as 
an  exaggeration  of  the  normal  dorsal  kyphosis  balanced  by  an 
exaggerated  lordosis,  ' '  the  rhachitic  attitude. "  And  in  other 
instances  the  persistence  of  the  lumbar  kyphosis  may  induce  a 
compensatory  flattening  of  the  normal  dorsal  kyphosis.  Thus, 
rhachitis  may  cause  the  so-called ^a^  back  as  well. 

It  may  be  mentioned  that  rotary  lateral  curvature  of  the  spine 
is  one  of  the  common  deformities  induced  by  rhachitis.  This 
distortion  is  far  more  serious  than  the  anteroposterior  curvature 
with  which  it  is  occasionally  combined.  Its  treatment  is  con- 
sidered in  Chapter  III. 

Infectious  Disease  of  the  Coverings  or  Articulations  of  the 
Spine.     "The  Typhoid   Spine." 

During  the  course  of  or  during  convalescence  from  typhoid 
fever,  and  occasionally  after  apparent  recovery  from  the  disease, 
symptoms  of  pain,  weakness,  and  stiffness  of  the  back  may 
appear.  These  are  caused  apparently  by  secondary  infection  of 
the  fibrous  coverings  and  attachments  of  the  spine,  similar  to  the 
more  common  but  more  severe  forms  of  periostitis  of  the  tibia  or 
other  bones,  from  the  same  cause.  There  is  usually  pain  on 
motion,  reflected  along  the  nerves.  In  some  instances  this  is 
extreme,  and  there  maybe  accompanying  muscular  "cramps" 
and  spasm,  and  pain  on  pressure  over  the  affected  vertebrae. 

In  many  instances  a  neurotic  element  is  present,  induced, 
doubtless,  by  the  preceding  disease.  In  8  of  26  cases  investigated 
by  Lord^  kyphotic  deformity  indicated  apparently  local  destruc- 
tiveness  of  the  process. 

Diagnosis.  The  diagnosis  is  usually  made  clear  by  the  history 
of  the  disease  of  *which  it  is  a  complication. 

Treatment.  The  treatment  should  be  symptomatic.  During 
the  active  stage,  if  pain  is  severe,  the  patient  should  be  kept  in 
the  recumbent  position  and  opiates  may  be  administered  if  neces- 
sary. Locally,  the  application  of  the  Paquelin  cautery  is  of  ser- 
vice. As  soon  as  is  practicable  a  back  brace  or  other  support 
should  be  applied,  which  should  be  worn  until  the  symptoms  have 
subsided.     Recovery  may  be  predicted,  the  duration  of  the  symp- 

1  Boston  Medical  and  Surgical  Journal,  June  26,  1902. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     135 

toms  averaging  about  six  months.     Slight  restriction  of  motion 
may  persist  in  the  more  severe  type  of  cases. 

This  description  applies  particularly  to  a  class  of  cases  of  a  mild 
type  described  by  Gibney  as  typhoid  spine.  Disease  of  the  spine 
complicating  typhoid  fever  was  first  described  by  Maisonneuve 
in  1835.  Terrillon^  classifies  the  lesion  of  typhoid  infection  of 
the  spine  as : 

1.  Simple  periostitis. 

2.  Periostitis  with  subperiosteal  abscess. 

3.  Periostitis  with  ostitis. 

In  sixty-eight  cases  tabulated  by  Wiirtz^  six  were  in  children 
under  ten  years  of  age. 

Symptoms  resembling  those  described  may  follow  other  forms 
of  contagious  disease,  notably  scarlet  fever,  but,  as  a  rule,  they 
are  much  less  persistent  and  severe. 

Infectious  Arthritis  of  the  Spine. 

^' Gonorrhoeal  rheumatism"  of  the  spine  is  uncommon.  Its 
symptoms  and  pathology  resemble  those  of  the  typhoid  spine. 
Anchylosis  is,  however,  more  common  as  a  result  than  after  other 
forms  of  infection  ;  in  fact,  gonorrhoea  is  supposed  to  be  one  of 
the  causes  of  spondylitis  deformans. 

The  treatment,  aside  from  that  of  the  exciting  cause,  is  symp- 
tomatic.     Local  support  is  indicated  in  many  instances. 

The  articulation  of  the  occipito-axoid  region  are  sometimes 
affected  by  what  appears  to  be  a  form  of  acute  or  subacute  infec- 
tious arthritis  similar  in  characteristics  to  acute  rheumatism.  It 
may  follow  tonsillitis,  diphtheria,  or  other  contagious  disease.  It 
may  be  distinguished  from  tuberculous  disease  by  its  acute  onset 
and  from  acute  torticollis  by  the  fact  that  all  motions  are 
restricted. 

Treatment.  The  treatment  consists  in  support  during  the 
acute  stage,  followed  by  massage,  manipulation,  and  exercise  to 
overcome  the  subsequent  stiffness. 

Spondylitis   Deformans. 

Synonyms.  Ostco-arthritis  of  the  spine ;  rheumatism  of  the 
spine ;  spondylose  rhizomelique ;  stiffness  of  the  vertebral  column. 

1  Le  Prog.  M6d.,  April  12,  1884. 

-  .Jahrbuch  lur  Kinrlerheilkunde,  .July,  1902 


136 


ORTHOPEDIC  SUBGEBY. 


Spondylitis  deformans  is  an  inflammatory  affection  of  the  spine 
terminating  in  anchylosis  and  deformity. 

Pathology.  The  disease  is  apparently  a  chronic  inflammation 
which  affects  primarily  the  ligaments  and  the  periosteal  coverings 
of  the  spine,  a  form  of  ossifying  periostitis  which  binds  the  ver- 
tebree  firmly  to  one  another  (Fig.  72).  It  may  begin  on  the 
lateral  or  on  the  anterior  aspect  of  the  spine ;  it  may  be  limited 
to  a  particular  region,  but  in  most  instances  it  involves  the  entire 


V"*^^*:! 


Spondylitis  deformaDS  (osteo-arlhritisj.    (Goldthwait.) 


spine  and  often  the  articulations  of  the  ribs  as  well.  The  inter- 
vertebral disks  atrophy,  and  the  spine  becomes  anchylosed.  In 
some  instances  the  margins  of  the  cartilages  proliferate  and 
become  ossified  in  a  manner  characteristic  of  osteo-arthritis  of 
the  joints. 

Under  the  general  term  of  spondylitis  deformans  are  included, 
in  all  probability,  several  varieties  of  disease,  for  example : 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     137 


1.  The  affection  of  the  spine  may  be  simply  one  of  the  mani- 
festations of  general  rheumatoid  arthritis — rheumatoid  arthritis 
of  the  spine. 

2.  The  spine  may  be  involved  together  with  one  or  more  of 
the  adjacent  joints  which  present  the  characteristic  symptoms  of 


Fig.  73. 


Fig.  74. 


Spondylitis  deformans,  illustrating 
the  characteristic  deformity.  Age  of 
the  patient,  thirty  years.  Spine 
rigid,  with  the  exception  of  the  oc- 
cipito-axoid  articulation.  Duration 
two  years ;  cause  unknown.  No 
joints  involved. 


Spondylitis  deformans  in  a  child. 


the  so-called  hypertrophic  form  of  arthritis  deformans — osteo- 
arthritis of  the  spine.  This  form  has  been  designated  by  Marie 
spondylose  rhizomelique,  spondylos-spine,  rhizo-root,  melos- 
extremity,  signifying  a  disease  of  the  spine  together  with  the 
adjoining  "•  root"  joints.^ 


1  Marie.    Revue  dc  M6d.,  18'.)8,  vol.  xviii 


138  OB THOPEDIC  SURGEB  Y. 

3.  The  disease  may  be  limited  to  the  spine,  and  in  such  cases 
it  appears  to  be  entirely  distinct  from  characteristic  rheumatoid 
arthritis  or  osteo-arthritis.  It  may  follow  acute  rheumatism,  it 
may  be  induced  apparently  by  gonorrhoea,  or  by  other  forms  of 
infection  or  by  injury — traumatic  spondylitis.  It  may  begin 
acutely,  like  inflammatory  rheumatism,  or  it  may  be  chronic  in 
character  and  progress  slowly/  It  may  be  limited  to  a  particular 
section  of  the  spine,  although,  as  a  rule,  the  other  regions  are 
progressively  involved. 

Symptoms.  In  the  ordinary  cases  there  is  usually  an  acute 
onset  from  which  the  patient  dates  the  beginning  of  his  trouble, 
often  so-called  lumbago,  followed  by  a  gradually  increasing 
stiffness  of  the  spine  and  accompanying  deformity.  The  patient 
complains  of  stiffness,  weakness,  pain  in  the  loins,  and  of  pain 
radiating  forward  along  the  ribs.  Sometimes  of  weakness  in  the 
limbs,  headache,  nervousness,  and  the  like — symptoms  that  may 
be  explained  in  part  by  the  inflammatory  process  and  by  impli- 
cation of  the  nerve  roots,  and  in  part  by  an  accompanying  neuras- 
thenia. The  direct  symptoms  are  increased  by  jars  which  are 
exaggerated  by  the  inelasticity  of  the  spine.  The  disease  is 
usually  progressive,  and  terminates  finally  in  complete  rigidity 
of  the  spine,  which  is  bent  into  a  long  kyphosis  most  marked  in 
the  upper  dorsal  region,  the  lumbar  lordosis  being  obliterated 
in  many  instances  (Fig.  73). 

The  straightening  of  the  spine  in  the  middle  and  lower  region 
exaggerates  the  forward  thrust  of  the  neck,  and  in  some  instances 
the  patients  complain  of  a  disturbance  of  equilibrium,  especially 
of  a  tendency  to  fall  forward. 

When  the  disease  is  limited  to  the  spine  or  to  the  spine  and 
one  or  more  of  the  larger  joints,  the  occipito-axoid  articulations 
are  not  usually  involved ;  but  in  the  general  form  of  the  disease — 
rheumatoid  arthritis — they  are  often  primarily  affected. 

The  types  of  the  disease  may  be  illustrated  by  a  brief  descrip- 
tion of  five  cases  recently  under  observation. 

Case  I.  Chronic  Rheumatoid  Arthritis  of  the  Spine.  In  this 
case,  in  a  boy  ten  years  of  age,  there  was  characteristic  general 
rheumatoid  arthritis  that  involved  nearly  every  joint  of  the  body. 
The  entire  spine,  even  including  the  occipito-axoid  joints,  was 
rigid  and  the  head  was  fixed  in  an  attitude  of  extreme  torti- 
collis. 

1  Bechterew.    Neurol.  Centralbl.,  vol.  li.  p.  426.    Senator.    Berlin,  klin.    Wochen.,  Novem- 
ber 20,  1897. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     139 

Case  II.  Osteo-arthritis  of  the  Spine.  "  Spondylose  rhizo- 
melique."  A  man,  aged  forty-six  years,  after  repeated  attacks 
of  so-called  rheumatism  involving  the  larger  joints,  became 
gradually  disabled  because  of  pain  and  stiffness  of  the  back  and 
because  of  his  inability  to  stand  erect.  In  this  case  there  was 
complete  anchylosis  of  the  spine,  except  of  the  small  joints  of  the 

Fig.  75. 


Extreme  posterior  curvature  of  the  spine  in  adolescence,  showing  retraction  of  the  abdomen. 
This  deformity  may  be  mistaken  for  spondylitis  deformans. 

cervical  region,  and  in  addition  the  right  thigh  was  flexed  upon 
the  body  at  such  an  angle  that  the  patient  could  walk  only  with 
an  exaggerated  stoop.  The  joints  of  the  feet  were  slightly  in- 
volved also.  No  cause  other  than  exposure  to  cold  and  dampness 
could  be  assigned.  The  symptoms  were  of  two  years'  duration, 
periods  of  comfort  alternating  with  disabling  attacks  of  "  rheu- 
matism." 


140  ORTHOPEDIC  SURGERY. 

Case  III.  Spondylitis  Deformans.  The  spine  of  this  patient,  a 
man  aged  forty-six  years,  was  absokitely  anchylosed  in  the  charac- 
teristic position.  The  occipito-axoid  joints  were  not  involved. 
Fourteen  years  before  he  had  suffered  from  a  severe  and  pro- 
longed attack  of  ' '  inflammatory  rheumatism, ' '  affecting  nearly 
every  joint,  but  not  the  spine,  and  during  a  succeeding  period 
of  nine  years  he  had  been  disabled  several  times  from  the  same 
cause.  Each  illness  was  coincident  with  gonorrhoea.  Five 
years  before  examination  the  "  rheumatism"  had  involved  the 
spine,  and  since  then  he  had  suffered  from  persistent  "  lumbago." 
Gradually  the  stiffness  of  the  spine  had  increased,  but  during 
this  time  he  had  been  free  from  gonorrhoea  and  from  rheumatism 
as  well.  The  joints  were  normal  in  appearance  and  function. 
This  patient  suffers  principally  from  nervousness  and  irritability ; 
he  is  easily  startled ;  he  feels  as  if  his  forehead  were  clasped  by  a 
tight  band.  His  direct  symptoms  are  pain  in  the  loins  and  pain 
radiating  under  the  shoulder-blades,  increased  by  walking  or  by 
jars.  His  equilibrium  is  disturbed  by  the  forward  projection  of 
the  head  and  by  the  obliteration  of  the  normal  lordosis,  so  that 
he  feels  himself  constantly  inclined  to  fall  forward,  whether  he 
is  sitting  or  standing. 

Case  IV.  In  another  case  very  similar  to  this,  in  a  man 
aged  thirty  years,  the  spine  had  become  rigid  in  a  few  months. 
The  patient  ascribed  the  disease  to  sleeping  out  of  doors.  There 
was  in  this  case  coincident  tuberculous  disease  of  the  lungs. 

Case  'V .  A  man,  aged  sixty-two  years,  presenting  the  char- 
acteristic deformity  and  symptoms  of  the  subacute  type,  gave  the 
following  account  of  the  affection :  Fifteen  years  before  he  had 
suffered  from  "  chronic  lumbago."  The  pain  and  stiffness,  at 
first  limited  to  the  lower  region  of  the  spine,  had,  with  interven- 
ing periods  of  remission,  gradually  ascended,  and  at  the  time  of 
examination  the  cervical  region  was  the  seat  of  the  more  active 
process.  He  had  been  treated  by  internal  remedies,  by  baths,  and 
by  change  of  climate,  without  avail.  He  knew  he  had  the  "  old 
man's  stoop,"  but  he  was  surprised  to  learn  that  the  source  of 
his  symptoms  was  a  disease  of  the  spine.  The  spine  was  rigid, 
although  not  anchylosed,  as  indicated  by  the  discomfort  on 
changing  from  one  position  to  another.  The  occipito-axoid 
articulations  and  the  other  joints  were  free  from  disease. 

This  subacute  form  of  the  affection  is  very  common,  and,  as  in 
this  instance,  the  patients  are  usually  treated  for  rheumatism,  mus- 
cular or  otherwise,  for  many  years  before  the  true  diagnosis  is  made. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     141 

Treatment.  The  local  treatment  is  symptomatic.  Massage 
of  the  muscles,  hot  baths,  and  the  like,  may  add  to  the  comfort 
of  the  patient,  but  violent  exercise  or  passive  movements  of  the 
spine  are  harmful.  Support  is  always  indicated  during  the  pro- 
gressive stage  of  the  affection,  and  it  is  the  only  efficient  remedy. 
The  support  may  be  in  the  form  of  a  light  brace  or  jacket.  It  is 
particularly  efficacious  when  the  disease  is  limited  to  the  lower 
and  middle  region  of  the  spine.  In  such  cases  under  efficient 
protection  the  muscular  spasm  subsides,  and  motion  returns  in 
some  degree.  Even  in  progressive  cases  one  may  hope  to  pre- 
serve the  lumbar  lordosis,  and  thus  lessen  the  general  effect  of 
the  deformity  when  the  spine  becomes  rigid.  In  certain  in- 
stances in  which  anchylosis  is  not  established,  force  may  be 
employed  to  improve  the  contour  of  the  spine,  particularly  with 
the  aim  of  re-establishing  the  lumbar  lordosis,  and  thus  enabling 
the  patient  to  stand  erect.  The  patient  learns  by  experience 
what  exercise  or  posture  increases  the  discomfort,  and  this 
should  be  avoided  if  possible.  The  application  of  cautery  is 
often  of  service,  and  self-suspension  at  intervals  may  relieve  the 
dragging  sensation  in  the  muscles.  Rubber  heels  are  of  service 
in  lessening  the  jar.  As  has  been  stated,  in  some  cases  the  dis- 
ease remains  localized,  but  ordinarily  it  extends  along  the  spine. 
When  a  part  of  the  spine  becomes  firmly  anchylosed  the  local 
discomfort  lessens  or  ceases,  and  is  transferred  to  the  part  where 
the  process  is  still  advancing. 

Kjrphosis  of  Adolescents.  A  form  of  extreme  kyphosis  accom- 
panied by  stiffness  and  discomfort  is  sometimes  seen.  It  appears 
to  be  a  static  deformity  induced  by  overwork  in  rapidly  growing 
adolescents,  which  finally  becomes  fixed  by  accommodative 
changes  in  the  bones  and  neighboring  tissues.  It  can  hardly 
be  classified  with  spondylitis  deformans,  although  there  may  be 
some  difficulty  in  distinguishing  between  the  two  (Fig.  75). 
In  favorable  cases  partial  rectification  of  the  deformity  by  force 
(the  Calot  operation)  is  indicated.  Afterward  support,  manipu- 
lation, and  exercises  should  be  employed. 

Osteitis  Deformans. 

Synonym.     Paget's  disease. 

Osteitis  deformans  is  a  general  disease  characterized  by  hyper- 
trophy and  softening  of  the  bones.  The  deformity  of  the  spine 
is  similar  to  that  of  spondylitis  deformans,  but  the  rigidity  is  not 


142 


ORTHOPEDIC  SUBOEBY. 


as  marked,  and   the  discomfort  is  far  less  than  in  this  affection. 
The  disease  is  described  elsewhere. 

Tabetic  Deformity  of  the  Spine.     In  rare  instances  deform- 
ity of  the  spine,  either  posterior  or  lateral,  appears  as  a  compli- 


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The  neurotic  spine.    Characteristic  attitude. 

cation  of  locomotor  ataxia.  Fifteen  cases  are  recorded.^  The 
characteristics  of  this  form  of  osteo-arthropathy  are  described 
elsewhere. 

The  Neurotic  Spine. 

The  "  neurotic "  spine  is  much  more  common  in  adolescence 
and  in  adult  life  than  in  childhood,  and  the  subjects,  usually 
females,  are  often  of  a  nervous  or  neurasthenic  type.     In  certain 


1  Cornell.    Bulletin  Johns  Hopkins  Hospital,  October,  1902. 


NON -TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     143 

instances  the  symptoms  appear  to  be  induced  by  injury,  and  in 
others  by  worry  or  overwork. 

Symptoms.  The  patient  usually  complains  of  a  dull  pain  in 
the  back  of  the  neck,  or  in  the  lumbar  or  sacral  region,  of  a  con- 
stant tired  feeling,  and,  not  infrequently,  of  sharp  neuralgic  pain 
localized  about  a  certain  point  in  the  spine,  often  the  vertebra 
prominens.  The  contour  of  the  spine  may  be  normal,  but  most 
often  there  is  a  well-marked  tendency  toward  a  forward  droop,  the 
curve  of  weakness  (Fig.  76).  One  of  the  common  symptoms  of 
the  neurotic  spine  is  the  extreme  local  tenderness,  or  hypersesthesia, 
of  the  skin  at  certain  points  along  the  spinous  processes.  Thus, 
if  one  passes  the  finger  gently  along  the  spine  the  patient  will 
often  shrink  or  cry  out  because  of  the  pain.  As  a  rule,  there  is 
no  limitation  of  motion  or  muscular  spasm.  The  pain  is  local, 
not  referred  to  the  terminations  of  the  nerves  ;  in  fact,  the  symp- 
toms are  in  great  part  subjective  and  irregular  in  character,  as 
contrasted  with  those  of  Pott's  disease,  which  are  objective  and 
well  defined. 

Treatment.  The  treatment  of  the  neurotic  spine  must  be 
general  in  character,  as  indicated  by  the  condition  of  the  patient. 
Locally,  a  light  back  brace  or  a  long  corset,  reinforced  if  neces- 
sary by  light  steel  back  bars,  adds  greatly  to  the  comfort  of  the 
patient.  The  application  of  the  cautery  is  particularly  efficacious 
in  relieving  the  local  sensitiveness.  Massage  and  light  exercises 
may  be  employed  in  the  later  treatment.  Complete  recovery  is 
usually  long  delayed. 

The  Hysterical  Spine. 

The  hysterical  spine  is  considered  usually  as  synonymous  with 
the  neurotic  spine,  but  as  there  are  many  individuals  who  suffer 
from  sensitive  spines  who  are  not  hysterical,  it  would  seem  proper 
to  limit  the  latter  term  to  the  hysterical  class. 

Symptoms.  The  local  symptoms  do  not  differ  particularly 
from  those  of  the  neurotic  spine  except  that  in  certain  instances 
actual  deformity  may  be  present.  This  is  usually  an  exaggerated 
lateral  distortion,  most  marked  in  the  lumbar  region.  Like 
hysterical  distortions  elsewhere,  it  may  follow  injury,  and  it  may 
be  claimed  that  this  injury  was  the  direct  cause  of  the  deformity. 
Excejit,  however,  as  a  possible  cause  of  the  appearance  of  a  par- 
ticular manifestation  of  the  mental  condition,  it  is  evident  that 
no  form  of  injury  could  explain  the  symptoms  or  the  deformity. 


144 


ORTHOPEDIC  SURGERY. 


Treatment.  The  local  treatment  is  similar  to  that  of  the 
neurotic  spine. 

Pain  in  the  Lower  Part  of  the  Back. 

Discomfort  in  the  lumbar  region  of  the  character  of  tire,  weak- 
ness, or  even  of  actual  pain  is  sometimes  an  accompaniment  of 
disease  or  displacement  of  the  pelvic  or  abdominal  organs.  Pain 
in  this  region  is  also  a  common  symptom  among  overworked 
women.  It  is  particularly  troublesome  when  for  any  reason  the 
lumbar  lordosis  is  exaggerated  temporarily,  as  during  pregnancy, 
or  permanently  as  a  compensatory  deformity  for  dorsal  Pott's 
disease,  or  because  of  flexion  of  the  thigh  after  hip  disease. 

As  a  result  of  strain  or  other  injury  symptoms  of  pain  and 
weakness  in  the  lumbar  region,  increased  by  sudden  motions  or 


Fig. 


Small  pelvis  of  Prague  (median  section).    Instance  of  slight  forward  displacement  of  fifth 
lumbar  vertebra.    (Neugebauer.) 

overexertion,  may  be  persistent  and  disabling.  Such  cases  are 
often  classed  as  chronic  lumbago,  but  it  is  probable  that  there  is 
in  many  instances  a  distinct  injury  of  the  ligaments  or  deep 
muscles  of  the  spine  aggravated,  it  may  be,  in  certain  instances, 
by  rheumatism  or  other  general  affection  of  like  character. 

The  treatment  must  be  primarily  directed  to  the  condition  of 
which  the  pain  is  a  symptom. 

When  motion  causes  pain  and  when  the  symptoms  are  per- 
sistent, as  in  the  lumbago  type  of  cases,  support  is  indicated,  the 
Knight  brace  or  plaster  corset  being  convenient  forms.  During 
the  more  acute  stage  the  application  of  the  cautery  and  the 
support  of  intersecting  strips  of  adhesive  plaster,  covering  a  wide 


NON-TUBEBCULOUS  AFFECTIONS  OF  THE  SPINE.     145 

area,  will  often  relieve  the  pain.      Later,  massage,  electricity, 
and  the  like  are  of  service. 

In  the  milder  cases,  in  which  the  symptoms  may  be  dependent 
on  a  general  descent  of  the  abdominal  and  pelvic  organs,  an 
abdominal  belt  will  afford  great  relief. 

Spondylolisthesis. 

Spondylolisthesis  is  a  deformity  in  which  the  body  of  one  of 
the  lower  lumbar  vertebrae,  most  often  the  fifth,  is  displaced  for- 
ward and  downward  (Fig.  77).  The  displacement  is  peculiar  in 
that  the  spinous  process  may  remain  in  its  normal  position,  while 
the  laminae  become  elongated  or  separated  from  the  displaced 
body.  The  condition  was  first  described  by  Killian  in  1854,  and 
it  was  thoroughly  investigated  by  Neugebauer^  in  1890. 

The  supposed  causes  are  congenital  malformation,  injury,  and 
possibly  disease  of  the  lumbosacral  articulation.  Lane  states 
that  slighter  degrees  of  the  deformity  are  often  observed  among 
laborers.  The  effect  of  the  displacement  is  to  exaggerate  the 
lumbar  lordosis,  to  increase  the  prominence  of  the  sacrum,  and  of 
the  iliac  crests,  and  to  shorten  the  trunk.  The  deformity  is 
most  often  seen  in  women ;  in  fact,  its  chief  interest  lies  in  its 
effect  upon  childbirth.  As  a  rule,  however,  as  has  been  stated 
in  the  preceding  section,  an  increase  of  the  lumbar  lordosis  is 
usually  attended  by  a  certain  degree  of  discomfort  and  pain.  In 
some  instances  the  deformity  induces  a  swaggering  gait  resem- 
bling that  of  bilateral  congenital  dislocation  of  the  hips. 

Lovett^  has  described  a  case  in  which  the  deformity  was  the 
result  of  direct  injury.  The  patient,  a  young  man,  was  success- 
fully treated  by  a  plaster  jacket.  Such  cases,  and  those  in  which 
displacement  is  the  result  of  disease,  may  require  orthopedic  treat- 
ment by  braces  or  other  support  for  the  relief  of  pain  and  for  the 
prevention  of  further  deformity.  In  the  milder  type  exercises 
and  posture  are,  as  a  rule,  sufficient. 

Deformity  Secondary  to  Sciatica. 

Synonym.     Sciatic  scoliosis. 

Chronic  sciatica  often  induces  a  change  in  the  attitude  and  con- 
tour of  the  spine  that  may  become  a  permanent  deformity  if  its 

'  Lovett.    Transactions  American  Ortliopedlc  Association,  vol.  x.  p.  22. 
^  Transactions  American  Ortliopedic  Association,  vol.  x. 

10 


146  ORTHOPEDIC  S UB GEB  Y. 

cause  persists.  As  a  rule,  the  patient  habitually  inclines  the 
body  away  from  the  painful  part  in  order  to  relieve  it  from 
weight,  and  bends  the  body  slightly  forward  and  abducts  the 
limb  to  relax  the  tension  on  the  sensitive  nerve  or  plexus  of 
nerves.  Thus,  the  pelvis  on  the  affected  side  projects,  there  is  a 
lateral  lumbar  convexity  toward  the  opposite  side,  and  often  the 
normal  lumbar  lordosis  is  lessened  or  lost  so  that  the  final  result 
may  be  a  persistent  lateral  curvature,  together  with  a  change  in 
the  anteroposterior  contour  of  the  spine.  If  the  deformity  per- 
sists a  second  compensatory  curve  may  appear  (Fig.  78).  If  the 
sciatica  is  a  symptom  of  a  more  widespread  neuritis,  muscular 
weakness  and  muscular  spasm  may  cause  variations  in  the  typical 
attitude,  the  muscles  of  one  side  being  persistently  contracted. 

It  must  be  borne  in  mind  that  disease  of  the  lumbar  spine,  or 
of  the  pelvic  bones  or  joints,  or  disease  of  the  adjacent  organs  or 
parts  may  set  up  sciatica ;  thus,  the  cause  of  pain  should  be  care- 
fully sought  for. 

Aside  from  the  direct  treatment  of  sciatica,  support  for  the 
spine,  preferably  a  light  corset,  may  be  indicated,  if  motion  aggra- 
vates the  pain.  If  the  deformity  persists  it  should  be  corrected 
gradually  by  repeated  applications  of  the  plaster  jacket. 

Neuritis  in  other  regions  of  the  spine  may  cause  symptoms  of 
reflected  pain  and  local  sensitiveness.  These  symptoms  are 
increased  by  motion,  and  a  certain  amount  of  local  deformity, 
similar  in  character  to  that  due  to  sciatica,  may  be  present. 

The  treatment  is  similar  to  that  indicated  in  the  former  affection. 

Sacro-iliac  Disease. 

Tuberculous  disease  of  the  sacro-iliac  articulation  is  a  rare  affec- 
tion, and  extremely  so  in  childhood. 

Symptoms.  The  symptoms  are  pain,  weakness,  limp,  and 
change  in  attitude.  The  pain  is  referred  to  the  side  of  the  pelvis 
or  radiates  over  the  buttock  or  thigh.  It  is  increased  by  jars, 
by  turning  the  body  suddenly,  sometimes  by  coughing  or  laugh- 
ing ;  and  a  peculiar  feeling  of  insecurity  and  weakness  is  some- 
times complained  of.  As  a  rule,  the  body  is  inclined  toward  the 
sound  limb ;  thus  the  pelvis  is  lowered  on  the  affected  side  and 
the  leg  seems  longer  than  its  fellow.  In  the  early  stage  of  the 
disease  there  is  no  deformity  of  the  limb,  but  if  a  pelvic  abscess 
forms  the  thigh  may  become  flexed.  Locally,  there  may  be  sen- 
sitiveness to  pressure  on  the  articulation,  and  swelling  in  the 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE.     147 


Fig.  78. 


neighborhood  of  the  disease,  although  this  is  usually  a  late  symp- 
tom. Pain  is  induced  by  lateral  pressure  on  the  pelvis  or  by 
any  manipulation  that  disturbs  the  articulation. 

Abscess  finally  forms  in  the  majority  of  cases.  It  may  be 
extrapelvic  or  intrapelvic.  The  intrapelvic  abscess  may  present 
above  the  crest  of  the  ilium,  or 
the  pus  may  pass  through  the 
sciatic  notch,  or  appear  in  the 
ischiorectal  fossa,  or  break  into 
the  rectum. 

Diagnosis.  Sacro-iliac  dis- 
ease may  be  mistaken  for  sciatica 
or  for  disease  of  the  hvp  or  spine. 
The  freedom  of  motion  and  the 
absence  of  muscular  spasm  when 
the  pelvis  is  fixed,  if  the  ex- 
amination is  carefully  conducted, 
should  exclude  both  the  one  and 
the  other,  although  the  pain  on 
lateral  pressure,  which  is  de- 
scribed as  the  most  characteris- 
tic symptom,  may  be  simulated 
closely  by  primary  acetabular 
disease.  The  attitude  is  similar 
to  that  of  sciatica,  but  the  symp- 
toms of  local  sensitiveness  to  jars 
and  to  manipulation  are  much 
more  marked. 

Prognosis.  According  to  the 
statistics  the  prognosis  is  very 
unfavorable,  probably  because  the 
majority  of  the  reported  cases 
were  in  adults  and  were  compli- 
cated by  infected  and  burrowing 
abscesses,  which  constitute  the 
chief  danger  of  this  form  of  tu- 
berculous disease. 

Treatment.  Tlie  local  treat- 
ment consists  in  protecting  the 
diseased  parts  from  injury  and  in  the  radical  removal  of  the 
disease  if  it  has  reached  the  stage  of  abscess  formation,  if  this  be 
feasible. 


Deformity  caused  by  persistent  sciatica 
of  the  right  side.  This  attitude  is  simi- 
lar to  that  symptomatic  of  sacro-iliac  dis- 
ease. 


148  ORTHOPEDIC  SURGERY. 

In  the  ambulatory  treatment  of  advanced  cases  a  plaster  spica 
bandage  or  a  double  Thomas  hip  brace  may  be  indicated,  but  in 
most  instances  a  broad,  strong  pelvic  girdle,  which  may  be  drawn 
tightly  about  the  pelvis,  will  be  most  efficient.  As  a  temporary 
support  wide,  encircling  bands  of  adhesive  plaster  may  be  used. 
If  motion  of  the  spine  causes  discomfort  a  spinal  brace  provided 
with  a  wide  pelvic  band  of  thin  steel  that  may  clasp  the  pelvis 
firmly  is  more  efficacious.  If  the  disease  is  progressive  rest  in 
bed  will  be  necessary. 

When  abscess  is  present  radical  treatment  is  usually  indi- 
cated. The  articulation  should  be  freely  exposed  and  the  dis- 
eased bone  should  be  entirely  removed,  if  possible.  Intrapelvic 
abscess  should  be  drained  through  a  direct  communication  in 
order  to  check,  if  possible,  the  tendency  toward  burrowing. 

Injury  of  the  Sacro-iliac  Articulation. 

In  some  instances  the  symptoms  of  sacro-iliac  disease  are 
apparently  due  directly  to  falls  on  the  buttock  or  pelvis  or  to 
strains.  In  such  cases  the  symptoms  are  similar  in  character 
to  those  described,  and  they  are  readily  relieved  by  the  same 
treatment. 


CHAPTER    III. 

LATERAL  CURVATURE  OF  THE  SPINE. 

Synonyms.     Rotary  lateral  curvature — scoliosis. 

Lateral  curvature  of  the  spine  is  an  habitual  or  fixed  deformity 
in  which  the  spine  is  deviated  in  whole  or  part  to  one  or  the 
other  side  of  the  median  line. 


Fig.  79. 


Physiological  rotation  accompanying  flexion  and  lateral  inclination  of  the  trunk  in  the 

normal  subject. 

By  limiting  the  term  to  habitual  deformity  one  excludes  simple 
postural  inclination  of  the  spine.  For  example,  if  one  leg  were 
considerably  shorter  than  the  other  the  pelvis  would  be  tilted 
downward  on  the  short  side,  and  there  would  be  a  compensatory 
curvature  of  the  spine  in  the  erect  attitude,  which  would  disap- 
pear in  the  sitting  posture.     This  accommodative  or  compensa- 


150 


ORTHOPEDIC  SURGERY. 


tory  inclinatiou,  and  those  o£  similar  origin,  are  not,  in  the  proper 
sense,  lateral  curvatures. 

In  persistent  lateral  curvature  the  anterior  part  of  the  column, 
made  up  of  the  bodies  of  the  vertebrse  that  support  the  weight,  is 
more  distorted  than  are  the  spinous  processes,  because  lateral  dis- 
tortion is  always  accompanied  by  a  certain  degree  of  twisting  or 
rotation  of  the  vertebral  bodies.      This  rotation  is  in  the  direction 


Fig.  80. 


Congenital  total  scoliosis.    Compare  with  Fig.  81. 

of  the  convexity  of  the  curve,  and,  as  the  bodies  rotate,  the 
spinous  processes  are  carried  in  the  reverse  direction.  Thus,  it  is 
that  well-marked  rotation  may  be  present,  although  there  may 
be  comparatively  little  lateral  deviation  of  the  line  of  the  spinous 
processes. 

In  the  physiological  movements  of  the  spine,  simple,  direct 
lateral  motion — that  is,  motion  allowed  by  the  small  joints  of  the 
spine  and  by  the  lateral  compression  of  the  intervertebral  disks — 


LATERAL  CURVATURE  OF  THE  SPINE.  151 

is  very  limited.  The  larger  movements  must  be  accompanied  by 
rotation  of  the  vertebral  bodies  by  which  this  continuous  or  solid 
part  of  the  column  is,  as  it  were,  forced  from  the  shortened 
toward  the  lengthened  side  (Fig.  79).  When,  for  example,  one 
flexes  the  head  to  bring  the  ear  as  near  the  shoulder  as  is  possible 
there  is  necessarily  an  accompanying  rotation  of  the  chin  in  the 
opposite  direction  caused  by  the  twisting  of  the  bodies  of  the 
cervical  vertebree  toward  the  convexity  of  the  curve.  Thus  torti- 
collis, in  which  the  neck  is  held  in  this  attitude,  causes  often  a 
fixed  rotary  lateral  curvature  of  the  cervical  vertebrae. 

In  the  simple  accommodative  lateral  inclination  of  the  body  to 
one  side  or  the  other,  the  change  in  contour  of  the  spine  would  be 
more  noticeable  if  it  could  be  observed  from  the  front  rather  than 
from  the  back,  and  as  lateral  curvature  is  simply  a  persistent 
deviation  of  the  spine,  one  of  the  so-called  static  deformities  which 
are  directly  induced  or  exaggerated  by  superincumbent  weight, 
it  is  probable  that  rotation  of  the  vertebral  bodies  precedes,  in 
most  instances,  the  lateral  distortion  that  first  attracts  attention. 

It  is  probable,  also,  that  slight  rotation  may  not  cause  at  once 
an  appreciable  degree  of  external  distortion,  and,  although  marked 
lateral  curvature  is  necessarily  combined  with  rotation,  yet  it  is 
possible  that  a  slight  degree  of  direct  lateral  deviation  may  exist 
unaccompanied  by  appreciable  rotation.  Rotation  is  usually 
understood  to  imply  fixed  deformity,  while  lateral  deviation  may 
mean  simply  an  habitual  posture  ;  but  it  is  far  simpler  to  consider 
the  two  as  parts  of  one  distortion.  The  true  and  important  dis- 
tinction is  between  habitual  deformity,  implying  the  habitual 
assumption  of  an  improper  attitude  in  which  the  accommodative 
changes  in  structure  have  not  advanced  sufficiently  to  prevent 
voluntary  or  passive  correction,  and  fixed  deformity  in  which  the 
changes  in  the  bones  and  other  tissues  have  made  cure  difficult 
or  impossible.  The  evidence  of  fixed  deformity  is  rotation  that 
persists  after  the  lateral  deviation  has  been  overcome.  It  persists 
because  the  early  and  important  changes  must  take  place  in  the 
bodies  of  the  vertebrae  that  support  the  weight,  but  there  is  no 
reason  to  believe  that  habitual  rotation  as  an  accompaniment  of 
habitual  lateral  curvature  may  not  be  corrected  if  it  be  treated  at 
the  proper  time. 

The  necessity  for  dividing  the  weight  about  the  centre  of 
gravity  in  order  to  balance  the  body  in  the  upright  position 
accounts  for  the  distribution  and  effects  of  lateral  curvature.  As 
the  normal   contour  of  the  spine  is  the  necessary  result  of  static 


152 


ORTHOPEDIC  SURGERY. 


conditions,  a  change  from  this  normal  relation  of  one  part  neces- 
sitates a  corresponding  change  elsewhere.  If  there  be  a  primary 
lumbar  curvature  and  rotation  to  the  left  in  the  lower  region,  a 
corresponding  lateral  deviation  and  rotation  to  the  right  in  the 
region  above  usually  develops,  thus  restoring  the  balance  of  the 
body.  This  explains  the  ordinary  S-shaped  or  double  curve  of 
scoliosis,  one  of  which  is  primary  and  the  other  secondary.  These 
curves  may  divide  the  spine  equally  or  there  may  be  a  long  and 
a  short  one,  and  occasionally  three  distinct  curves  may  be  present. 
If  the  primary  curve  is  slight,  the  secondary  curvature  will  be 


Fig.  si. 


Congenital  total  scoliosis.    The  rotation  is  much  greater  than  the  lateral  deviation. 
Compare  with  Fig.  80. 

slight  also,  and  the  primary  curve  persists  doubtless  for  a  time 
before  the  secondary  distortion  appears.  In  some  instances  the 
spine  may  be  bent  laterally  into  one  long  curve,  "  total  scoliosis  " 
(Fig.  80).  This  is  probably,  in  many  instances  at  least,  the 
initial  stage  of  the  ordinary  type  of  scoliosis,  the  long  curve  being 
afterward  divided,  although  it  may  persist.  In  childhood  total 
scoliosis  is  often  combined  with  general  posterior  curvature,  and 
it  is  peculiar  in  that  the  torsion  of  the  vertebrae  may  be  toward 
the  concave  instead  of  the  convex  side,  as  is  usual,  the  torsion 
representing  probably  the  early  stages  of  the  secondary  or  com- 
pensatory curve. 


LATERAL  CUBVATURE  OF  THE  SPINE. 


153 


It  has  been  stated  that  deformity  of  one  part  of  the  spine  is 
usually  balanced  by  deformity  of  another.  This  enables  the 
trunk  to  hold  the  erect  posture,  and  it  restores  its  general  sym- 
metry.    If,  however,  a  long  lateral  or  a  long  posterior  curvature 


Fig.  82. 


Primary  lumbar  curvature  to  the  left.    A  "  flat  back  "  marked  rotation  with  but  slight 

lateral  curvature. 

persists,  the  weight  can  be  balanced  only  by  swaying  the  entire 
body  on  the  pelvis,  in  the  direction  opposed  to  the  distortion. 
This  restores  the  balance,  but  not  the  symmetry  (Fig.  94). 


Rotation  and  Lateral  Deviation. 

Fixed   rotation   of  the  spine  carries  with  it,  of  course,  all  the 
parts  that  are  attached  to  it.   When  the  patient  stands  in  the  erect 


154 


ORTHOPEDIC  SURGERY. 


attitude  the  simple  lateral  distortion  is  most  noticeable  (Fig.  80), 
but  when  the  body  is  bent  forward  the  twist  of  the  trunk  becomes 
the  prominent  deformity  (Fig.  81),  If  the  thoracic  region  is 
involved,  the  ribs,  on  the  side  toward  which  the  spine  is  rotated, 
project  backward,  and  on  the  other  side  of  the  spine  there  is  an 
abnormal  flatness  or  depression.  The  projection  of  the  ribs  due 
to  the  twisting  of  the  thorax  is  far  more  noticeable  than  is  the 
simple  twisting  of  the  free  portions  of  the  spine  in  the  neck  or 


Fig.  83. 


Scoliosis  with  marked  posterior  delormity. 


loins ;  and  in  these  regions  the  projecting  transverse  processes 
covered  by  the  thick  layers  of  muscles  yet  unaccompanied  by 
marked  lateral  deviation,  may  cause  mistakes  in  diagnosis.  In 
the  cervical  region,  for  example,  as  an  accompaniment  of  acute 
torticollis,  the  projection  may  be  mistaken  for  abscess;  and  in 
the  lumbar  region  it  has  been  mistaken  for  a  new-growth  attached 
to  the  spine. 


LATERAL  CURVATURE  OF  THE  SPINE.  I55 

Although  persistent  lateral  curvature  of  the  spine  is  always 
accompanied  by  rotation,  the  degree  of  rotation  does  not  always 
correspond  to  that  of  the  more  evident  lateral  deviation.  In  the 
instance  cited,  rotation  in  the  lumbar  region,  so  extreme  as  to 
simulate  an  abnormal  growth,  may  exist  with  but  slight  lateral 
distortion  ;  while  in  other  cases  the  body  appears  to  be  greatly 
displaced  to  one  side,  although  there  may  be  comparatively  little 
fixed  rotation.  Again,  as  has  been  stated,  the  lateral  deviation 
of  the  trunk  is  usually  more  noticeable  than  the  rotation,  which 
in  the  slightest  grades  of  deformity  is  only  made  apparent  when 
the  patient  is  bent  forward  so  that  the  back  may  be  inspected  in 
the  horizontal  position.  It  may  be  noted,  also,  that  the  degree 
of  habitual  lateral  distortion  of  the  body  does  not  correspond  to 
the  degree  of  fixed  distortion.  One  individual,  by  voluntary 
effort,  may  practically  conceal  advanced  deformity,  while  another 
who  makes  no  effort  to  correct  the  improper  posture  appears  to 
be  greatly  distorted,  although  the  fixed  changes  may  be  very 
slight. 

The  effects  of  the  deformity,  both  general  and  local,  depend 
upon  its  situation  and  its  degree.  In  one  instance  it  may  be  so 
slight  as  to  pass  unnoticed,  and  in  another  the  distortion  may 
equal  that  of  Pott's  disease  (Fig.  83).  If  compensation  be  per- 
fect— that  is,  if  the  deformity  is  equally  distributed  on  either 
side  of  the  median  line — the  general  symmetry  of  the  body  may 
be  but  slightly  disturbed.  Or,  if  the  compensation  for  the 
primary  deformity  of  the  lumbar  region  is  distributed  throughout 
the  remainder  of  the  spine,  noticeable  distortion  may  be  insig- 
nificant, but  when  there  is  a  long  curve  involving  the  thoracic 
region  the  lateral  and  posterior  displacement  cannot  be  concealed 
(Fig.  <S4). 

Changes  in  the  Anteroposterior  Contour. 

Lateral  distortion  involves,  also,  secondary  changes  in  the 
anteroposterior  outline  of  the  spine.  When  the  distortion  is 
marked  the  stature  is  shortened,  sometimes  very  noticeably. 
This  shortening  is,  of  course,  greater  when  the  anteroposterior 
curves  are  increased  in  addition  to  the  lateral  deviation.  And, 
in  general,  one  may  recognize  two  types  of  lateral  curvature :  one 
in  which  the  back  is  flatter  than  normal,  in  which  the  antero- 
posterior curves  are  diminished,  and  another  in  which  they  are 
increased. 

It  has  been  stated  in  the  account  of  J^ott's  disease  that  deform- 


156  OB THOPEDIG  S  UB  GEB  Y. 

ity  in  one  segment  of  the  spine  always  caused  a  change  in  the 
contour  of  the  spine  as  a  whole,  that  an  obliteration  or  a  lessen- 
ing of  the  concavity  of  the  lumbar  region  was  accompanied  by  a 
corresponding  flattening  of  the  normal  dorsal  kyphosis.  On  the 
other  hand,  that  an  increase  in  the  backward  projection  of  the 
dorsal  region  caused  an  increase  in  the  concavity  of  the  parts  below. 
The  variations  in  the  anteroposterior  contour  of  the  spine  in 
lateral  curvature  may  be  accounted  for  in  the  same  manner.  In 
the  one  instance  the  primary  deformity  is  of  the  lower  region, 
and  with  its  accompanying  backward  twist  of  the  vertebral  bodies 
it  lessens  the  lumbar  lordosis  and  tends  to  flatten  the  back 
(Fig.  82).  If,  on  the  other  hand,  the  deformity  begins  in  the 
thoracic  region,  the  primary  effect  is  to  increase  the  backward 
projection,  and  this  in  turn  tends  to  exaggerate  the  lumbar 
lordosis  (Fig.  88).  Thus,  the  shortening  of  the  trunk  in  the 
lumbar  region  caused  by  the  lateral  deviation  may  be  to  a  certain 
extent  compensated  in  the  first  instance,  while  in  the  other  both 
the  primary  and  secondary  distortions  tend  to  reduce  the  height. 

The  "High"  Shoulder  and  the  "High"  Hip. 

When  the  convexity  of  the  primary  curve  is,  for  example,  to 
the  left  in  the  lumbar  region,  the  trunk  is  displaced  somewhat 
to  the  left,  consequently  the  right  "  hip "  becomes  abnormally 
prominent ;  and  in  compensation  for  the  displacement  below 
there  is  a  corresponding  twist  in  the  opposite  direction  above. 
The  spine  bending,  and  at  the  same  time  rotating  toward  the 
right,  carrying  with  it  the  ribs,  elevates  the  shoulder  and  makes 
the  scapula  prominent.  Thus  it  is  that  in  the  ordinary  S-shaped 
curve  the  high  shoulder  and  the  projecting  hip  appear  usually 
upon  the  same  side  of  the  body.  But  in  less  regular  varieties  of 
distortion,  when,  for  example,  there  is  marked  general  lateral 
deviation  of  the  trunk  as  a  whole,  the  high  shoulder  may  be  on 
the  opposite  side  (Fig.  84).  It  is  probable  that  the  primary  curv- 
ature is  commonly  in  the  lumbar  region  and  toward  the  left,  the 
compensation  to  the  right  appearing  at  a  later  time.  This  is 
certainly  true  of  the  milder  types  of  postural  curvature. 

Pathology.  Lateral  curvature  of  the  spine  is  a  deformity, 
not  a  disease,  nor  is  it  in  the  ordinary  cases  an  effect  of  disease. 
For  this  reason  the  description  of  the  pathology  which  is  merely 
a  more  detailed  account  of  the  deformity  and  of  its  secondary 
effects  upon  the  trunk  and  its  contents  may,  for  convenience, 
precede  the  discussion  of  the  etiology. 


LATERAL  CURVATURE  OF  THE  SPINE. 


157 


In  such  a  description  one  must  consider  the  spine  as  a  whole,  a 
column  bent  and  twisted,  in  which  each  component  segment  bears 
its  share  of  the  general  distortion.  The  vertebra  at  the  apex  of 
each  curve  shows  the  greatest  change.  If  the  rotation  and  lateral 
deviation  is  to  the  right  the  vertebral  body  is  somewhat  wedge- 
shaped,  the  apex  of  the  wedge  being  directed  backward  and  to 
the  left.     Its  lateral  diameter  is  increased  and  the  superior  and 


Fig.  84. 


Scoliosis  with  extreme  lateral  deviation. 


inferior  margins  at  the  narrow  side  overhang  the  centre  of  the 
body,  increasing  its  lateral  concavity  (Fig.  88).  Similar  accom- 
modative changes,  although  less  marked,  are  to  be  found  in  the 
articular  ])rocesses  and  in  the  larninie  ;  in  fact,  all  the  parts  on 
the  concave  side  are  broadened,  shortened,  and  lessened  in  vertical 
diameter  as  compared  with  those  on  the  convex  side  of  the  spine. 
These  changes  affect  the  shape  of  the  neural  canal,  which  becomes 


158 


ORTHOPEDIC  SURGERY. 


somewhat  ovoid  in  outline,  the  base  being  directed  toward  the 
convexity  of  the  curve  (Fig.  89).  In  the  vertebrae,  inckided  in 
the  compensatory  curvature,  the  deformities  are  reversed,  and 
the  intermediate  segments  show  the  transitional  changes  between 


the  two  extremes.  The  intervertebral  disks  become  wedge-shaped 
also,  and  atrophied  on  the  side  subjected  to  greatest  pressure,  the 
changes  in  these  softer  tissues  preceding,  undoubtedly,  those  in 


LATERAL  CURVATURE  OF  THE  SPINE. 


159 


the  bones.  The  articulations  of  the  vertebrae  become  changed  in 
shape  and  position  in  the  general  adaptation  to  the  deformity 
and  the  ligaments  are  shortened  or  lengthened  according  to  their 
relation  to  the  distortion. 

On  section  the  internal  structure  of  the  vertebrae  shows  the 
same  adaptive  changes  that  are  evident  on  the  exterior.  In  the 
narrowed  parts  of  the  bones  that  bear  the  weight  the  tissue  is 
thick  and  compact,  and  on  the  opposite  side  it  is  attenuated  and 
atrophied. 

The  mobility  of  the  spine  is  lessened  by  these  changes  in  its 
shape    and   structure,  primarily  by  the  distortion,   later   by  the 


Fig.  88. 


Scoliotic  vertebrae.    (Hoffa). 

shortening  of  the  tissues  on  the  concave  side,  by  the  irregularities 
of  the  vertebral  bodies,  by  the  interference  of  the  newly  formed 
or  transformed  bone  which  is  thrown  out  about  the  margins  of 
the  vertebrae  and  the  articular  processes,  and  by  ossification  of 
the  periosteum  and  ligamentous  coverings  of  the  adjacent  bones. 
Thus,  in  fixed  deformity  there  may  be,  at  the  points  of  greatest 
distortion,  practical  anchylosis.  The  muscles  of  the  back,  both 
intrinsic  and   extrinsic,  undergo  adaptative  changes,  and,   as  a 


160  OR THOPEDIC  S UR GER  Y. 

rule,  they  are,  in  general,  relatively  weak,  especially  so  if  the 
motions  of  the  spine  are  much  interfered  with. 

The  distortion  of  the  vertebral  column  causes,  of  course,  a  dis- 
tortion of  the  trunk  of  which  it  is  the  support,  and  this  distortion 
is  of  the  greatest  importance  in  its  effect  upon  the  thorax.  The 
deformity  of  the  thorax  is  somewhat  difficult  to  describe,  because 
the  distortion  of  the  dorsal  vertebrae  does  not  affect  the  thorax 
equally ;  thus,  it  is  not  twisted  as  a  whole,  nor  flexed  as  a  whole. 
The  nature  of  the  deformity  may  be  better  understood  by  consid- 
ering the  sternum  as  a  fixed  point;  this,  as  a  matter  of  fact,  it  is, 
as  compared  with  the  spine.  At  the  apex  of  the  convexity  of 
the  curve  the  ribs  are  drawn  sharply  backward  with  the  trans- 
verse processes  to  which  they  are  attached;  their  angles  project 
by  the  side  of  and  beyond,  sometimes  covering  and  concealing 
the  spinous  processes,  and  the  lateral  convexity  of  the  chest  is 
diminished  or  lost.  On  the  opposite  side  the  back  is  broadened 
and  flattened.  The  effect  of  the  rotation  is  to  diminish  the 
capacity  of  the  chest  on  the  convex  side,  and  to  increase  that  of 
the  concave  side  (Fig.  90).  On  the  convex  side  the  ribs  are 
elevated,  and  their  inclination  is  increased.  On  the  concave  side 
the  intercostal  spaces  are  narrowed  and  the  inclination  is  lessened 
(Fig.  87).  The  anteroposterior  diameter  of  the  chest  is  increased 
or  diminished  according  to  the  change  in  the  anteroposterior 
contour  of  the  spine.  If  the  dorsal  kyphosis  is  exaggerated  the 
effect  is  to  deepen  the  chest  (Fig.  83)  ;  if  it  is  diminished,  the 
diameter  of  the  thorax  is  correspondingly  lessened. 

The  cervical  section  of  the  spine  is  not  often  involved,  to  a 
marked  degree  at  least,  in  the  lateral  deformity.  But  in  extreme 
cases,  in  which  the  neck  and  head  are  habitually  distorted,  the 
skull  may  show  secondary  changes  similar  to  those  induced  by 
persistent  torticollis. 

At  the  other  extremity  of  the  spine  the  pelvis  is  not,  as  a  rule, 
noticeably  deformed.  In  some  instances  the  oblique  diameter, 
opposed  to  the  convexity  of  the  lumbar  deformity,  may  be  in- 
creased, and  if  the  lateral  deviation  of  the  lumbar  spine  is  extreme 
the  pelvis  may  be  so  tilted  that  the  limb  on  the  elevated  side 
becomes  practically  shorter  than  its  fellow. 

In  the  changes  that  have  been  described  the  contents  of  the 
trunk  participate  to  a  greater  or  less  degree.  The  lung  on  the 
convex  side  is  more  or  less  compressed  by  the  distorted  ribs  and 
by  the  displaced  vertebral  bodies.  The  heart  may  be  displaced 
laterally  or  upward,  according  to  the  position  of  the  deformity, 


LA TERAL  CURVATURE  OF  THE  SPINE.  161 

and  the  bloodvessels  are  changed  in  direction,  and,  it  may  be, 
altered  in  calibre.  In  those  cases  in  which  the  thorax  is  markedly 
distorted  the  effect  is  similar  to  that  of  the  deformity  of  Pott's 
disease  ;  respiration  is  shallow  and  rapid,  the  pulse-rate  is  usually 
increased,  and  other  evidences  of  interference  with  the  vital 
functions  may  be  apparent.  The  abdominal  organs  are  affected, 
doubtless,  in  a  similar  manner,  but  symptoms  due  to  this  cause 
are  not,  as  a  rule,  as  clearly  marked.^ 

Bachmann  investigated  the  secondary  changes  induced  by 
severe  scoliotic  deformity  coming  under  his  observation  in  the 
pathological  institute  of  Breslau.  In  91.3  per  cent,  of  the  sub- 
jects defect  or  disease  of  the  circulatory,  and  in  99.1  per  cent,  of 
the  respiratory  apparatus,  was  observed. 

Etiology.  Relative  Frequency.  Lateral  curvature  of  the  spine 
is  one  of  the  most  common  of  deformities.      In  a  period  of  fifteen 

Fig.  89. 


Change  in  shape  of  the  spiual  canal,  broader  on  the  convex  side.    (Hoffa.) 

years — 1885-1899 — 3252  cases  were  recorded  in  the  out-patient 
department  of  the  Hospital  for  Ruptured  and  Crippled,  a  number 
only  exceeded  by  that  of  bow-legs,  of  which  5030  cases  were 
treated  during  the  same  period. 

The  'statistics  bearing  upon   the   relative  frequency  of  lateral 

'  Bachmann.    Die  Veriinderungen  an  den  inneren  Organen  bci  hochgradigen  Skoliosen 
und  Kyphoskoliosen.    Bibllotbeca  Medica,  Ab.  D.  1,  H.  4,  1900. 

11 


162 


ORTHOPEDIC  SURGERY. 


curvature  among  children  in  general  are  those  of  Drachmann, 
who  found  among  28,125  school-children  (16,789  boys,  11,386 
girls)  of  Denmark  368  cases  of  scoliosis  (1.3  per  cent.),  and 
those  of  Scholder,  Werth,  and  Combe, ^  who  found  571  cases  of 
lateral  curvature  among  2314  school-children  of  Switzerland 
(24.6  per  cent.),  a  discrepancy  that  is  somewhat  difficult  to 
explain. 

Sex.  Lateral  curvature  of  the  spine  is  far  more  common 
among  females  than  males.  Of  the  3252  cases  referred  to,  2554 
(78.5  per  cent.)  were  in  females  and  698  (21.4  per  cent.)  were  in 
males. 

Fig.  90. 


Deformity  of  the  thorax  in  scoliosis.    (Hoffii.) 

The  lowest  percentage  of  males  in  any  one  of  the  fifteen  years 
Avas  14.8,  the  highest  25.1.  This  proportion  of  one  male  to  four 
females  is  somewhat  larger  than  in  the  smaller  groups  of  cases 
reported  by  other  observers. 

The  unequal  distribution  of  the  deformity  between  the  sexes 
is  of  great  interest  as  bearing  on  the  question  of  etiology ;  espe- 
cially so  as  in  the  cases  that  develop  in  early  childhood,  sex 
appears  to  exercise  practically  no  influence.  It  has  been  sug- 
gested that  curvature  of  the  spine  in  a  girl  is  looked  upon  with 
more  solicitude  by  the  mother  than  is  the  same  deformity  in  a 
boy,  therefore,  more  girls  are  brought  for  treatment.  There  may 
be  some  basis  for  this  argument,  for  it  is  certain  that  distortions 
of  the  lower  extremities  are  considered  of  greater  importance  in 
male  than  in  female  children,  because  of  the  concealment  to  be 


1  Extrait  des  Annals  Suisses  d'Hygiene  Scolaire,  1901. 


LATERAL  CURVATURE  OF  THE  SPINE.  163 

afforded  by  the  skirts,  if  the  deformity  is  not  outgrown.  But 
granting  that  statistics  are  somewhat  unreliable,  there  can  be  no 
doubt  but  that  this  deformity  is  far  more  common  among  girls 
than  boys  and  that  the  disproportion  may  be  explained,  in  great 
part  at  least,  by  the  differences  in  dress  and  in  manner  of  life. 

Age.  One  thousand  two  hundred  and  ninety -nine  (39.9  per 
cent.)  of  the  3252  patients  referred  to  were  less  than  fourteen 
years  of  age;  1576  (48.4  per  cent.)  were  between  fourteen  and 
twenty-one';  377  (11.6  per  cent.)  were  more  than  twenty-one 
years  of  age.  These  statistics  simply  show  the  age  of  the  patients 
at  the  time  treatment  was  sought,  and  they  are  of  little  value 
as  an  indication  of  the  age  at  which  deformity  might  have  been 
detected  had  it  been  looked  for. 

There  is  no  reason  to  suppose  that  lateral  curvature  of  the 
spine  differs  in  its  etiology  from  similar  deformities  of  other 
parts,  except  in  so  far  as  each  region  of  the  body  is  more  or  less 
susceptible  to  deforming  influences  at  one  time  than  another. 

For  example,  rhachitic  deformities  of  the  upper  extremities 
practically  never  develop  except  in  infancy,  and  they  begin  to 
correct  themselves  when  the  erect  posture  is  assumed  or  at  the 
very  time  when  distortions  of  similar  origin  of  the  lower  extrem- 
ities appear  or  increase.  When  deformities  of  this  class,  whether 
of  the  spine  or  limbs,  appear  in  later  childhood  or  adolescence  it 
may  be  assumed  that,  in  many  instances  at  least,  the  tendency 
toward  the  particular  deformity,  or  even  a  slight  degree  of 
deformity,  was  acquired  at  an  early  age,  that  it  remained  latent 
until  the  conditions  appeared  which  favored  its  further  develop- 
ment. This  point  is  illustrated  by  the  statistics  of  Eulenburg 
of  1000  cases  of  lateral  curvature  analyzed  with  reference  to  the 
inception  of  the  deformity. 

Between  birth  and  the  sixth  year 78 

"        the  sixth  and  seventh  years 216 

"        the  seventh  and  tenth  years 564 

"        the  tenth  and  fourteenth  years 107 

After  the  fourteenth  year 35 

1000 

It  will  be  noted  that  but  142  (14.2  per  cent.)  of  these  patients 
were  more  than  fourteen  years  of  age  as  contrasted  with  the 
general  statistics  of  the  Hospital  for  Ruptured  and  Crippled,  in 
which  60  per  cent,  were  beyond  this  age. 

Dr.  Walter  Truslow,  who  for  several  years  had  the  immediate 
charge  of  the  treatment  of  lateral  curvature  at  the  Hospital  for 
Ruptured    and  Crippled,   has    prepared   for    me   statistics  of  a 


164 


ORTHOPEDIC  SUBOEBY. 


number  of  the  cases  treated  by  gymnastic  exercises,  which  illus- 
trate the  same  point. 

A. — Age  when  Treatment  was  Begun. 


Age  ivhen  e. 

lamined.                                                    Males. 

Females. 

Total 

4  ye 

ars 0 

1 

1 

5      ' 

0 

1 

1 

6 

1 

1 

2 

7      ' 

4 

2 

6 

8      ' 

4 

7 

11 

9      ' 

4 

4 

8 

10      ' 

<             .2 

7 

9 

11 

3 

13 

16 

12 

3 

16 

19 

13      ' 

4 

28 

32 

14      • 

5 

25 

30 

15      ' 

3 

21 

24 

16      ' 

8 

14 

22 

17      ' 

2 

6 

8 

18      ' 

1 

2 

3 

19      ' 

0 

1 

20      ' 

0 

1 

21 

0 

4 

23      ' 

0 

1 

24      • 

0 

1 

32      ' 

0 

1 

B. — Age  when  the  Deformity  was  Discovered. 


Males. 


Females. 


Congenital  (sex  not  stated) 

2 

During  infancy  (sex  not  stated) 

.    19 

Between  3  and    6  years  . 

.    16 

10 

6 

6    "    10      "      . 

.    41 

10 

31 

10    "    13      "      . 

.    62 

6 

56 

13    •'    15      "      . 

.     27 

3 

24 

Over        15  years       .... 

.     14 

3 

11 

Unlinown 

.     20 

201 


But  44  of  the  181  patients  (22.6  per  cent.)  were  more  than 
thirteen  years  of  age  at  the  time  when  the  deformity  was  first 
noticed,  although  nearly  50  per  cent,  were  older  than  this  when 
treatment  was  applied  for.  In  the  first  table  it  will  be  noted 
that  of  the  38  patients  who  were  ten  years  of  age  or  less  15,  or 
about  40  per  cent,  of  the  number,  were  males.  In  25  of  the  37 
patients  in  whom  the  deformity  attracted  attention  at  or  before 
the  sixth  year  rhachitis  was  the  apparent  cause. 

Lateral  curvature  of  the  spine  is  one  of  the  penalties  of  the 
erect  posture,  and  the  force  of  gravity  must  be  considered  both 
as  a  predisposing  and  as  an  exciting  cause  of  the  deformity. 

The  more  direct  tendency  of  the  force  of  gravity  is  to  cause 
the  body  to  fall  forward  and  to  increase  the  posterior  curvature 
of  the  spine,  but  whenever  there  is  a  persistent  inclination  of  the 


LATERAL  CURVATURE  OF  THE  SPINE.  165 

spine  to  one  or  the  other  side  this  inclination  is  likely  to  be  in- 
creased to  deformity  under  favoring  conditions.  These  favoring 
conditions  would  include  general  weakness  from  any  cause ;  over- 
work that  may  induce  fatigue,  and  all  factors,  mechanical  or 
otherwise,  that  may  add  to  the  difficulty  of  holding  the  trunk 
erect  under  the  pressure  of  the  superincumbent  weight. 

Although  it  is  not  difficult  to  suggest  the  predisposing  causes 
of  lateral  curvature,  it  is  by  no  means  as  easy  to  point  out  the 
direct  cause  of  the  original  inclination  of  the  spine  to  one  or  the 
other  side  of  the  median  line  that  is  the  first  step  toward  fixed 
deformity.  In  a  certain  number  of  cases,  however,  the  relation 
between  cause  and  effect  is  sufficiently  evident,  and  these  causes 
may  be  enumerated  before  considering  the  larger  class  in  which 
the  etiology  is  more  obscure. 

1.  Lateral  curvature  secondary  to  deformity  of  other  parts. 

2.  Static  or  compensatory  deformity. 

3.  Deformity  secondary  to  disease  of  the  nervous  system. 

4.  Deformity  secondary  to  disease  of  the  thoracic  organs. 

5.  Incidental  deformity. 

6.  Deformity  due  to  occupation. 

7.  Congenital  deformity. 

8.  Rhachitic  deformity. 

1.  Lateral  Curvature  Secondary  to  Deformity  Else- 
where, (a)  Lateral  curvature  of  the  spine  may  be  a  compen- 
satory effect  of  torticollis,  either  congenital  or  acquired.  (6)  It 
may  be  induced  by  distortion  or  inequality  of  the  lower  extrem- 
ities. For  example,  fixed  adduction  of  the  thigh  necessitates  an 
upward  tilting  of  the  pelvis  whenever  the  limb  is  brought  into 
the  normal  line,  whether  the  patient  is  standing,  sitting,  or 
lying ;  and  this  deformity  when  extreme  may  induce  lateral 
curvature  even  in  bedridden  patients. 

2.  Compensatory  Deformity.  The  same  effect  is  sometimes 
observed  in  certain  instances  of  inequality  of  the  length  of  the 
lower  extremities.  In  the  erect  posture  the  pelvis  is  tilted  down- 
ward on  one  side,  and  this  in  turn  necessitating  a  twist  of  the 
spine.  Simple  inequality  of  the  limbs  is  an  occasional  but  not  a 
common  cause  of  fixed  deformity,  because  its  influence  ceases  in 
the  sitting  and  reclining  postures,  and  because  the  inequality  is 
so  often  compensated,  if  it  be  extreme,  by  walking  on  the  toe  or 
by  raising  the  sole  of  the  shoe. 

An  increase  in  the  length  of  a  limb,  such  as  may  be  caused  l)y 
a  fixed  equinus  of  the  foot,  seems  to  have  more  influence  in  cans- 


166  ORTHOPEDIC  SURGERY. 

ing  secondary  deformity  than  does  shortening,  because  no  attempt 
is  made  to  compensate  for  the  inequality. 

3.  Lateral  Curvature  Secondary  to  Paralysis.  Lat- 
eral deformity  of  the  spine  may  be  caused  indirectly  by  a  number 
of  distinct  diseases  of  the  nervous  system,  but  in  this  connection 
only  one  need  be  considered — anterior  poliomyelitis.  This  form 
of  paralysis  may  act  in  several  ways.  It  may  induce  deformity 
by  distortion  of  a  lower  extremity  or  by  inequality  in  the  length 
of  the  limbs  due  to  retardation  of  growth.  It  may  predispose 
to  deformity  by  the  general  weakness  that  it  causes,  or  the  trunk 
may  be  unbalanced  by  loss  of  function  in  one  of  the  upper 
extremities,  but  the  more  extreme  cases  of  deformity  are  caused 
by  unilateral  paralysis  of  the  muscles  of  the  trunk.  As  a  result, 
the  expansion  of  one  side  of  the  thorax  is  interfered  with  and  the 
unaffected,  or  less  affected,  side  taking  on  increased  activity, 
develops  at  the  expense  of  the  disabled  part.  Thus,  the  con- 
vexity of  the  curve  is  usually  toward  the  sound  side. 

4.  Lateral  Curvature  Secondary  to  Disease  within 
the  Thoracic  Walls.  The  most  common  cause  of  deformity 
of  this  class  is  persistent  empyema.  The  lung  is  primarily  com- 
pressed by  the  effused  fluid,  and  its  function  is  finally  impaired 
or  abolished  by  the  adhesions  that  form  between  it  and  the  chest 
wall,  as  well  as  by  the  extension  of  the  disease  to  its  structure. 
As  a  result,  the  side  of  the  chest  is  retracted  while  the  function  of 
the  unaffected  lung  is  increased  (Fig.  91).  Thus,  as  in  paralysis, 
the  spine  curves  with  the  convexity  toward  the  active  side. 

Other  affections  of  the  lungs  that  interfere  with  the  function ' 
of  one  side  may  induce  lateral  curvature,  but  the  influence  is  less 
marked  and  direct  than  in  empyema. 

5.  Incidental  Lateral  Curvature.  Lateral  curvature 
may  be  caused  by  direct  injury  or  by  disease  of  the  spine  ;  for 
example,  by  fracture  or  by  Pott's  disease,  or  by  other  organic 
affections  of  the  spine  (Fig.  92).  Distortion  symptomatic  of 
sacro-iliac  disease,  or  the  more  marked  deformity  caused  by 
sciatic  or  lumbar  neuritis  (Fig.  78),  may  if  persistent  finally 
induce  slight  permanent  deformity,  but  such  cases  hardly  deserve 
special  consideration. 

6.  Lateral  Curvature  due  to  Occupation.  Lateral 
curvature  of  a  mild  degree  is  incidental  to  certain  occupations  that 
require  habitual  inclination  of  the  body.  It  is  said  to  be  very 
common  among  stone-cutters,  for  example.  Such  deformity 
developing  after  the  growth  of  the  body  has  been  attained  is  of 


LATERAL  CURVATURE  OF  THE  SPINE. 


167 


interest  as  throwing  light  upon  the  etiology  of  the  ordinary  form 
of  lateral  curvature.  For  if  habitual  attitudes  can  thus  change 
the  contour  of  the  developed  spine,  it  is  evident  that  similar 
postures,  though"  far  less  constant,  may  inflaence  the  spine  of  a 
growing  child,  particularly  in  one  predisposed  to  such  distortion. 


Scoliosis  following  empyema  at 
the  age  of  two  years.  Present  age 
nineteen  years. 


Scoliosis  secondary  to  lumbar  Pott's  disease  in 
early  childtiood. 


7.  Congenital  Lateral  Curvature.  Congenital  scoliosis 
is  uncommon  in  infants  otherwise  normal  (Fig.  93),  but  several 
cases  have  come  under  my  observation  at  an  age  sufficiently 
early  to  make  the  diagnosis  absolutely  certain.  One  case,  in 
an  otherwise  well-formed  male  infant,  was  seen  at  the  age  of 
three  months.  There  was  well-marked  lateral  deviation  with 
rotation  in  the  dorsal  region  that  had  attracted  attention  soon 
after  birth.     A  second  case,  in  a  female  child,  was  seen  at  about 


168 


OB  THOPEDIC  S  UB  GEB  Y. 


the  same  age.  The  deformity  was  extreme,  and  contracted 
tissues  on  the  concave  side  prevented  the  straightening  of  the 
spine.     There  Avas  also  an  accompanying  lumbar  hernia. 

The  first  patient  was  cured  by  manipulation  and  posture  before 
the  completion  of  the  first  year ;  the  second  is  still  under  treat- 
ment. A  number  of  cases  have  been  collected  from  literature 
by  Hirschberger.^ 


Fig.  93. 


Fig.  94. 


Congenital  scoliosis. 


Khachitic  scoliosis. 


8.  Rhachitic  Lateral  Curvature.  Rhachitis  predisposes 
to  deformity  of  all  parts  of  the  body  by  weakening  the  resistance 
of  all  the  tissues.  As  is  well  known,  the  common  deformities 
from  this  cause  are  the  so-called  rhachitic  kyphosis  that  develops 
in  the  sitting  child,  and  the  distortions  of  the  lower  extremities 
in  those  who  stand  and  walk.     Lateral  curvature  of  the  spine 


1  Beitriig  zur  Lehr  der  Angeboren  Skoliosen.    Zeits.  f.  Ortho.  Chir.,  1899,  B.  vii.,  H.  1. 


LATERAL  CURVATURE  OF  THE  SPINE.  169 

sometimes  accompanies  the  kyphosis  in  those  who  do  not  walk, 
or  it  may  exist  independently  of  it.  The  lateral  inclination  is 
induced  doubtless  by  the  manner  of  sitting  or  by  the  manner  in 
which  the  child  is  supported  on  the  mother's  arm  ;  for  at  this 
period  of  rapid  growth  and  increased  susceptibility  to  deforming 
influences,  even  slight  and  temporary  causes  of  this  nature  may 
be  sufficient  to  induce  the  distortion  (Fig.  94).  Again,  when 
the  child  begins  to  walk,  the  tilting  of  the  pelvis  due  to  distortion 
of  the  limbs,  for  example,  to  unilateral  knock -knee,  may  also 
serve  to  disturb  the  equilibrium  of  the  body  and  thus  to  induce 
lateral   distortion. 

How  common  rhachitic  lateral  curvature  may  be  it  is  impos- 
sible to  say,  but  it  is  probable  that  if  all  rhachitic  infants  and 
children  were  carefully  examined  this  deformity  would  be  dis- 
covered in  many  instances  in  which  its  existence  had  not  been 
suspected. 

Mayer^  examined  220  rhachitic  infants  with  reference  to  this 
point,  and  in  all  but  3  found  scoliotic  deformity.  This  is  not  in 
accord  with  my  own  experience,  but  I  am  convinced  that 
rhachitis  is  of  far  greater  importance  in  the  etiology  of  lateral 
curvature  of  the  spine  than  is  generally  believed,  and  that  a 
large  proportion  of  the  severe  and  intractable  cases  may  be  traced 
to  this  cause. 

In  about  15  per  cent,  of  the  cases  tabulated  by  Truslow  the 
influence  of  one  or  more  of  the  causes  that  have  been  enumerated 
seemed  to  be  apparent,  viz. : 

Congenital  deformity 2 

Torticollis 2 

Empyema 4 

Anterior  poliomyelitis 3 

Inequality  of  the  legs  of  more  tban  half  an  inch 6 

Rhachitis 13 

Total 30 

In  the  remaining  85  per  cent,  of  the  cases  the  direct  cause 
of  the  deformity  was  uncertain. 

Hereditary  Influence.  By  many  writers  the  influence  of  heredity 
is  considered  an  important  factor  in  the  etiology.  That  there  is 
such  an  influence,  predisposing  to  disease  as  well  as  to  deformity, 
is  undoubted,  but  it  is  very  difficult  to  establish  its  connection 
with  the  ordinary  cases.  In  eleven  of  201  cases,  lateral  curvature 
was  present  in  either  the  father  or  mother  of  the  patient ;  and  in 

'  Bull.  M(:'dical,  June  15,  1901. 


170  OE THOPEDIC  SUBGEB  Y. 

seventeen  others  a  brother  or  sister  of  the  patient  was  deformed 
in  a  similar  manner. 

OccuPATiox.  It  is  well  known  that  occupation  may  induce 
deformity  in  the  adult,  and  one  looks  naturally  to  occupation  as 
a  factor  in  the  causation  of  lateral  curvature  in  childhood.  Occu- 
pation in  this  class  implies  school,  and  it  is  well  known  that 
fatigue  during  school  hours  may  induce  improper  postures,  espe- 
cially if  the  chair  is  unsuitable  or  uncomfortable.  The  influence 
of  habitual  posture  is  indicated  in  the  statistics  of  lateral  curvature 
among  school-children  recorded  by  Scholder,  AYerth,  and  Combe,^ 
the  proportion  of  deformity  steadily  rising  from  the  lower  to 
the  higher  classes  (Figs.  95  and  96).  Under  the  influence  of  con- 
stantly recurring  fatigue  an  improper  attitude  is  likely  to  become 
habitual,  its  character  being  influenced  by  the  arrangement  of  the 
light  or  by  the  shape  of  the  desk.  When  a  habit  of  posture  is 
acquired  it  is  likely  to  persist  when  the  sitting  posture  is  assumed 
elsewhere  than  at  school,  and  the  greater  liability  of  girls  to  the 
deformity  may  be  explained  in  part  by  the  fact  that  they  sew,  or 
read,  or  play  on  the  piano,  while  boys  are  usually  engaged  during 
the  same  period  in  active  exercise. 

In  400  cases  of  lateral  curvature  under  treatment  at  the  Hos- 
pital for  Ruptured  and  Crippled,  the  occupation  and  other  habits 
that  may  have  influenced  the  deformity  were  recorded  : 

Occupation : 

School 285 

Factory ....  19 

Clerk 13 

Domestic 8 

Millinery,  dressmaking,  etc 8 

Messenger 3 

Housewife 3 

Teacher 2 

No  occupation 59 

Total 400 

Posture : 

Weight  on  right  foot 48 

"        "    left       " 48 

-  96 
Carries  books  or  baby  on  right  arm 38 

"   left       " 36 

—  74 

Sits  at  desk  or  work  in  faulty  attitude 57 

Carries  heavy  load  on  one  shoulder 2 

Excessive  use  of  right  arm  in  occupation 3 

Total 232 

The  sitting  posture  is  not  the  only  one  in  which  improper 
attitudes  may  be  persistently  assumed,  in  fact,  it  has  been  sug- 
gested that  the  posture  during  sleep  may  influence  the  inclination 

1  Loc.  cit. 


LATERAL  CURVATURE  OF  THE  SPINE. 


Ill 


of  the  body  during  the  hours  of  activity.  But  the  sitting  posture 
is  the  one  in  which  the  muscular  support  is  most  likely  to  be 
relaxed,  and  in  which  a  tendency  toward  lateral  inclination  is 
most  likely  to  be  acquired,  since  children  do  not  often  retain  a 
fixed  attitude  in  the  erect  posture  for  any  length  of  time.  Brad- 
ford and  Lovett  record  an  observation  of  the  attitudes  of  sixty- 
seven  healthy  adults  undergoing  a  written  examination.  At  the 
end  of  the  second  hour  a  lateral  inclination  of  the  body  was  evident 
in  all,  and  in  three-fourths  of  the  number  the  general  inclination 


Fig.  95. 


Posture  induced  by  improper  desk  aud  chiair.    (Scudder.) 


of  the  body  was  to  the  right.  In  about  this  proportion  of  the 
cases  of  lateral  curvature  the  type  of  fixed  deformity  is  to  the  left 
in  the  lumbar  and  to  the  right  in  the  dorsal  region,  and  it  is 
natural  to  look  upon  the  occupation  as  the  important  factor  in 
determining  the  direction  of  the  deformity.  If  it  be  assumed 
that  the  distortion  is  caused  or  influenced  by  the  attitude  assumed 
during  school  hours  it  would  appear  that  the  primary  deformity 
should  be  more  often  of  the  lumbar  region,  for  in  the  sitting 
posture  the  lumbar  lordosis  is  lessened  or  lost,  thus  the  bodies  of 


172 


OR THOPEDIC  SUBGER  Y. 


the  vertebrae  in  the  lumbar  region  are  subjected  to  greater  pressure 
than  in  the  dorsal  region — a  pressure  which  might  induce  the 
accommodative  changes  in  the  bones  that  accompany  persistent 
deformity. 

The  possibility  of  distinguishing  the  varieties  of  lateral  curva- 
ture in  which  the  primary  distortion  is  lumbar  from  those  in 
which  it  is  dorsal,  by  the  flattening  of  the  dorsal  kyphosis  in  the 
former,  and  its  exaggeration  in  the  latter  instance,  has  been 
mentioned. 

Fig.  96. 


Posture  induced  by  improper  chair.    (Scudder 


Varieties  of  Deformity.  According  to  statistics  from  various 
sources,  about  three-fourths  of  the  well-developed  double  curves 
of  the  spine  are  convex  to  the  right  in  the  dorsal  and  to  the 
left  in  the  lumbar  region,  and,  as  the  distortion  of  the  thorax 
is  more  noticeable  of  the  two,  it  usually  classifies  the  deformity 
as  right  or  left.  The  dorsal  curvature  may  be  either  primary  or 
secondary,  and  the  relative  frequency  of  the  original  deformity, 
whether  lumbar  or  dorsal,  is  in  doubt,  with  the  probability  in 
favor  of  the  former. 

Summary  of  varieties  of  deformity  of  the  spine  under  treatment, 
1899-1900,  at  the  Hospital  for  Ruptured  and  Crippled,  tabulated 
by  Dr.  Truslow : 


LATERAL  CURVATURE  OF  THE  SPINE.  173 


1.  Simple  Anteroposterior  Deformities  : 

(a)  Kyphosis 10 

Kypholordosis 1 

Lordosis ^19 

Round  shoulders : 

(6)  Abducted  scapulae 7 

Elevated  scapulae 2 

2.  Anteroposterior  Abnormalities  Most    Marked,  but  Accompanied  by 

Lateral  Deviation : 

(a)  With  single  lateral  curve 14 

(6)  With  double  lateral  curves 16 

(c)  With  triple  lateral  curves 7 

3.  Rotation  More  Marked  than  Lateral  Deviation  : 

(a)  With  double  lateral  curves 22 

(6)  With  triple  lateral  curves 8 

4.  Lateral  Deviation  More  Marked  than  Rotation  ;  Direction  of  the  Curves  : 

Right  dorsal,  left  lumbar  type : 

(a)  Single  lateral  curve 22 

(6)  Double  lateral  curves 71 

(c)  Triple  lateral  curves ^     oo 

Left  dorsal,  right  lumbar  type : 

(a)  Single  lateral  curve 3 

(&)  Double  lateral  curves 8 

(c)  Triple  lateral  curves 3 

—      14 

Total 201 

It  will  be  noted  that  in  twenty-one  instances  anteroposterior 
deformity  existed  without  lateral  deviation,  and  that  in  thirty- 
seven  instances  it  was  accompanied  by  lateral  deviation.  In  the 
remaining  144  cases,  rotation  was  more  marked  than  lateral  devia- 
tion in  30  cases,  and  lateral  deviation  more  marked  than  rotation 
in  113.  In  the  entire  number  of  cases  in  which  lateral  deviation 
was  present  it  was  single  in  39  cases,  double  in  117  cases,  triple 
in  24  cases. 

In  890  cases  of  lateral  curvature  tabulated  by  Schulthess  the 
deformity  was  as  follows  •} 

Left.         Right.        Total. 
Total  scoliosis  (single  curve  afifecting  the  entire 

spine) 173  23  196 

Lumbar  scoliosis  (single  curve  limited  to  the 

lumbar  region) 63  34  97 

Lumbodorsal  scoliosis  (single  curve  limited  to 

lumbodorsal  region) 184  164  348 

Complicated  scoliosis  : 

(a)  Right  dorsal,  left  lumbar 191 

(b)  Left  dorsal,  right  lumbar    ....      58  ...  249 

478  412  890 

It  will  be  noted  that  a  very  large  proportion  of  these  cases 
were  in  the  early  stage  of  deformity,  as  indicated  by  the  absence 
of  compensatory  curves  ;  that  in  80  per  cent,  of  the  293  cases  in 

1  Zeits.  f.  Orth.  Chir.,  1902,  Bd.  x. 


1 74  ORTHOPEDIC  S UB GEB  Y. 

which  the  curve  was  general  or  most  marked  in  the  lumbar 
region,  the  inclination  was  to  the  left,  and  of  the  complicated  or 
more  fully  developed  cases  in  which  the  curve  was  double,  73  per 
cent,  were  of  the  right  dorsal,  left  lumbar  type. 

Symptoms.  In  the  large  proportion  of  cases  the  first  symp- 
tom is  the  deformity.  This  is  often  discovered  by  the  dress- 
maker at  the  age  when  the  clothing  is  made  to  fit  the  figure  more 
closely.  In  certain  instances  the  deformity  may  be  preceded  or 
accompanied  by  pain.  This  was  present  to  a  greater  or  less 
degree  in  about  one-quarter  of  the  cases  examined  by  Truslow. 
Pain  may  be  simply  the  discomfort  or  the  "  dragging  "  sensation 
of  fatigue,  usually  referred  to  the  lumbar  region,  or  it  may  be 
severe  and  neuralgic  in  type.  The  latter  variety  is  more  common 
in  the  cases  in  which  the  deformity  is  extreme.  It  is  said  to  be 
the  result  of  pressure  on  nerves,  but  this  cause  is  exceptional  in 
ordinary  cases,  as  it  is  as  often  referred  to  the  convex  as  to  the 
concave  side.  When  the  deformity  is  extreme — for  example, 
when  the  ribs  and  the  iliac  crest  are  in  contact — direct  pressure 
undoubtedly  explains  the  local  discomfort  referred  to  this  region. 
There  are  also  more  general  symptoms  of  a  neurasthenic  or 
hysterical  nature  that  may  be  due  in  part  to  the  deformity  and 
in  part  to  the  debility  of  which  it  may  be  a  result  or  accom- 
paniment. For  it  must  be  borne  in  mind  that  lateral  curvature 
is  often  symptomatic  of  general  weakness,  as  is  shown  by  the 
fact  that  it  is  often  accompanied  by  other  deformities,  par- 
ticularly by  the  weak  foot.  In  many  instances  symptoms  of 
weakness  and  awkwardness  precede  the  deformity.  Truslow 
states  that  in  a  large  proportion  of  the  cases  investigated  the 
patients  had  been  distinctly  less  active  than  their  companions, 
that  they  did  not  enjoy  exercise,  and  were  inclined  to  lead  seden- 
tary lives.  Teschner^  has  called  attention  to  the  same  peculiarity. 
He  states  that  the  patients  are  often  indifferent,  apathetic,  and 
lazy.  He  has  noted  also  a  peculiar  lack  of  co-ordination  and  mus- 
cular control  as  a  common  accompaniment  of  the  deformity. 
These  symptoms  apply  particularly  to  the  period  of  adolescence, 
the  time  of  rapid  growth  and  instability,  when  any  latent 
deformity  or  weakness  is  likely  to  be  exaggerated.  In  younger 
subjects  such  symptoms  are  far  less  marked  or  are  absent.  In 
the  cases  in  which  the  deformity  is  extreme,  symptoms  due  to 
interference  with  the  respiratory  and  circulatory  apparatus,  or  to 

1  Medical  Record,  December  16, 1893. 


LATERAL  CURVATURE  OF  THE  SPINE.  175 

displacement  of  the  abdominal  organs,  may  be  present.  These 
are,  however,  rather  unusual. 

Diagnosis.  Posture.  Lateral  curvature  of  the  spine  is  a 
simple  deformity  unaccompanied  by  the  symptoms  of  disease. 
When  the  patient  stands  with  the  back  and  hips  bare,  the  inclina- 
tion of  the  body  to  one  or  the  other  side  and  the  general  want 
of  symmetry  are  usually  apparent,  even  in  the  earliest  stage  of 
the  affection.  For,  as  has  been  stated,  the  habitual  assumption 
of  a  certain  posture  precedes  fixed  changes  in  and  about  the  spine, 
and  this  posture  will  appear  when  the  patient  is  asked  to  stand 
in  the  usual  manner.  If  the  inclination  of  the  body  is  toward 
the  left  (Fig.  80),  the  left  arm  will  hang  in  close  apposition  to 
its  lateral  border,  while  on  the  right  side  an  interval  will  appear 
between  the  arm  and  the  trunk.  If  there  be  a  slight  lumbar 
curve  to  the  left  (Fig.  82),  the  right  iliac  crest  will  be  accent- 
uated. The  curvature  in  the  dorsal  region  makes  one  shoulder 
higher  than  the  other  (Fig.  91),  the  scapula  on  the  affected  side 
projects,  and  the  distance  between  its  posterior  border  and  the 
median  line  is  increased.  Rotation  of  the  spine  is  shown  by  the 
fulness  or  projection  of  one  side  accompanied  by  a  corresponding 
flatness  on  the  other.  This  is  more  noticeable  when  the  patient 
bends  the  body  forward  so  that  the  horizontal  plane  of  the  back 
is  brought  into  view  (Fig.  81).  Corresponding  changes,  though 
of  a  less  marked  degree,  appear  on  the  anterior  surface  of  the 
body ;  for  example,  the  apparent  diminution  in  the  size  of  the 
mamma  on  the  side  opposite  the  convexity  of  the  posterior  curve 
and  its  relative  depression  or  elevation  may  attract  attention. 

It  seems  probable  that  a  change  in  the  anteroposterior  contour 
of  the  spine  precedes,  in  many  instances,  the  lateral  deviation. 
Thus,  a  general  droop  of  the  body  associated  with  round  shoulders 
and  a  flattening  of  the  chest  may  be  regarded  as  a  predisposing 
cause  or  an  early  symptom  of  more  serious  deformity. 

Mobility.  As  has  been  stated,  it  may  be  assumed  that  habitual 
posture  precedes  actual  deformity.  Habitual  posture  implies  dis- 
use of  certain  attitudes  and  motions,  thus  limitation  of  the  normal 
flexibility  of  the  spine  may  be  considered  as  one  of  the  earliest 
signs  of  progressive  deformity.  The  test  of  the  motion  of  the 
different  regions  of  the  spine  is,  therefore,  a  necessary  part  of  the 
examination.  To  test  the  motion  in  the  lumbar  region,  one  fixes 
the  pelvis  with  the  hands  while  the  patient  sways  the  body  in 
the  four  directions  and  rotates  it  from  side  to  side.  It  is  sug- 
gested by  Bradford  and  Lovett  that  direct  lateral  flexibility  may 


176 


ORTHOPEDIC  SURGERY. 


be  tested  by  placing  blocks  of  wood  under  one  foot  until  the  limit 
of  lateral  flexion  is  reached,  as  shown  by  the  inability  of  the 
patient  to  hold  the  elevated  limb  in  the  extended  position.  The 
experiment  is  then  repeated  on  the  opposite  side.  The  flexibility 
of  the  upper  part  of  the  trunk  may  be  tested  by  fixing  the  part 
below  with  the  hands  while  the  patient  flexes,  extends,  and  rotates 
the  body.  It  is  important,  also,  to  test  the  range  of  motion  at 
the  shoulder-joints.     The  normal  individual  should  be  able  to 


Fig.  97. 


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The  thread  screen.    From  the  Boston  Children's  Hospital  Report. 


hold  the  arms  extended  directly  above  the  head  without  Increas- 
ing the  lumbar  lordosis.  In  many  instances,  however,  it  will  be 
found  that  there  is  a  marked  restriction  of  this  motion  ;  in  fact, 
such  restriction  is  almost  always  an  accompaniment  of  so-called 
round  shoulders. 

The  height  and  weight,  the  circumference  and  the  expansion 
of  the  chest  should  be  investigated,  and  a  test  of  the  muscular 


LATERAL  CURVATURE  OF  THE  SPINE.  177 

strength,  not  only  of  the  muscles  of  the  trunk,  but  of  the  mem- 
bers as  well,  is  of  advantage  as  throwing  light  on  the  etiology 
and  indicating  the  general  line  of  treatment. 

Record,  The  most  reliable  of  the  graphic  records  to  be  used 
in  connection  with  the  history  are  photographs.  The  patient 
may  stand  behind  a  thread  screen  (Fig.  97)  in  the  habitual  atti- 
tude. The  spinous  processes,  the  iliac  crests,  and  the  angles  of 
the  scapulae  having  been  marked,  the  exact  amount  of  lateral 
deviation  of  the  trunk  will  be  shown.  The  rotation  may  be  indi- 
cated also  by  photographing  the  patient  in  the  recumbent  posture. 

The  rotation  of  the  spine  is  the  most  important  indication  of 
deformity.  This  may  be  recorded  with  sufficient  accuracy  by 
taking  direct  tracings  of  half  the  trunk  at  fixed  points  by  means 
of  a  lead  or  zinc  tape  while  the  patient  lies  in  the  recumbent 
posture. 

At  the  Hospital  for  Ruptured  and  Crippled  the  shadow  of  the 
trunk  cast  by  an  electric  light  at  a  fixed  distance  is  traced  upon 
a  large  sheet  of  paper.  Upon  this  outline  the  position  of  the 
more  important  landmarks  is  indicated.  The  degree  of  rotation 
is  shown  by  transverse  tracings  and  the  line  of  the  spinous 
processes  is  ascertained  by  applying  a  broad  strip  of  adhesive 
plaster  to  the  back  upon  which  the  tip  of  each  spinous  process  is 
marked.  The  anteroposterior  outline  of  the  spine  should  be 
recorded,  also  the  general  attitude  and  the  presence  or  absence 
of  other  evidences  of  weakness  such  as  knock-knees  and  weak 
feet. 

Prognosis.  In  the  development  of  lateral  curvature  there  is 
doubtless  a  preliminary  or  predisposing  stage — a  stage  of  progres- 
sion and  a  stage  of  arrest.  All  deformities  of  this  class  are  more 
likely  to  progress  during  the  growing  period.  They  are  likely 
to  become  stationary  when  the  period  of  growth  is  completed. 
Thus,  the  prognosis  is  worse  when  the  deformity  begins  at  an 
early  age  than  when  it  first  appears  in  adolescence.  The  most 
extreme  and  intractable  of  the  simple  cases  are  the  result  of 
rhachitis,  in  which  the  deformity  appearing  in  infancy  or  early 
childhood  has  increased  with  the  growth  of  the  child. 

If  the  causes  of  deformity  are  such  that  they  operate  to  check 
the  equal  development  of  the  affected  part,  the  prognosis  is  even 
more  directly  influenced  by  the  age  of  the  patient.  For  example, 
empyema,  even  if  the  lung  is  irreparably  damaged,  does  not  cause 
appreciable  deformity  in  tlie  adult,  but  in  childhood  the  functional 
activity  and  the  growtli  of  tlie  side  of  the  thorax  are  checked,  in 

12 


178  ORTHOPEDIC  S  UR  GER  Y. 

addition  to  the  direct  effect  of  the  adhesions  and  contractions  due 
to  the  disease ;  thus,  the  deformity  is  Hkely  to  be  progressive  in 
spite  of  the  treatment.  The  same  is  true  of  paralytic  deformity. 
In  the  ordinary  type  of  lateral  curvature  in  the  adolescent  girl, 
the  prognosis  is  influenced,  of  course,  by  the  general  condition 
of  the  patient  and  by  the  character  of  the  occupation.  As  far 
as  the  local  deformity  is  concerned,  the  prognosis  as  regards  im- 
provement or  cure  depends  in  great  measure  upon  the  fixed  changes 
that  have  taken  place,  and  upon  the  degree  of  voluntary  and 
involuntary  rectification  that  is  possible.  In  some  instances  the 
postural  distortion  may  be  considerable,  yet  the  fixed  deformity 
may  be  very  slight,  while  in  other  instances  the  fixed  rotation  of 
the  spine  may  be  marked,  although  the  lateral  distortion  is  less 
noticeable. 

A  single  curve  is  more  amenable  to  treatment  than  is  a  double 
or  triple  distortion,  because  it  indicates  an  earlier  stage  of 
deformity  and  because  the  treatment  may  be  more  effective  when 
applied  to  one  deformity  than  to  several.  If,  however,  the  single 
curve  is  fixed,  the  appearance  of  a  secondary  or  compensatory 
curve  at  another  part  of  the  spine  is  probable,  in  spite  of  pre- 
ventive treatment. 

In  the  majority  of  cases,  fixed  deformity  of  the  spine  as  indi- 
cated by  rotation  is  already  present  when  the  patient  is  brought 
for  treatment.  This  fixed  deformity  might  be  overcome  doubt- 
less in  certain  cases,  and  complete  cure  might  be  obtained  Avere 
all  the  conditions  favorable.  But  in  the  ordinary  sense  a  cure 
means  the  relief  of  symptoms,  the  checking  of  the  progress  of 
deformity,  and  the  restoration  of  the  general  symmetry  of  the 
trunk.  Such  a  cure  may  be  obtained  in  most  instances.  The 
deformity  of  the  spine  becomes  symmetrically  divided  on  either 
side  of  the  median  line,  the  changes  incident  to  maturity,  par- 
ticularly the  increased  amount  of  adipose  tissue,  serve  to  con- 
ceal the  irregularities  of  the  outline,  and  the  history  of  the 
distortion  is  completed. 

In  certain  instances,  particularly  in  well-marked  cases,  the 
deformity  may  increase  in  adult  life  and  even  in  old  age.  In 
such  cases,  the  symptoms  of  discomfort  and  actual  pain  may  be 
troublesome  throughout  life,  especially  in  the  overworked  and 
debilitated  class.  The  symptoms  directly  incident  to  the  com- 
pression and  distortion  of  the  internal  organs  have  been  men- 
tioned. 

The  great  majority  of  cases  that  develop  or  that  are  discovered 


LATERAL  CURVATURE  OF  THE  SPINE.  179 

in  adolescence  progress  for  a  time  and  come  to  au  end  on  the 
cessation  of  growth,  causing  finally  no  symptoms  other  than  the 
loss  of  symmetry  that  may  be  more  or  less  satisfactorily  concealed 
by  the  art  of  the  dressmaker  and  by  the  corset. 

It  would  appear,  then,  that  lateral  curvature  of  the  spine  is 
always  of  sufficient  gravity  to  merit  treatment  and  supervision 
until  its  cure  or  arrest  is  assured.  If  its  discovery  leads  to  active 
efforts  to  improve  the  general  condition  and  to  avoid  unhealthful 
influences  it  may  be  even  of  benefit  to  the  patient. 

Lateral  curvature  in  a  young  child  is  of  far  greater  importance 
because  of  the  probability  of  an  increase  of  deformity.  Extreme 
deformity  is  always  a  source  of  weakness  and  usually  of  discom- 
fort to  the  patient.  Incipient  deformity  may  be  cured  and  cure 
is  not  impossible  even  when  deformity  is  more  advanced,  but  in 
this  more  than  in  any  other  postural  deformity,  absolute  cure 
implies  early  diagnosis  and  prevention,  rather  than  the  correction 
of  fixed  distortion. 

Recapitulation.  It  seems  probable  that  in  the  ordinary  type 
of  lateral  curvature  of  the  spine  the  first  step  is  a  change  in  the 
relation  of  the  bodies  of  the  vertebrse  to  one  another ;  that  a 
persistent  lateral  inclination  and  rotation  of  the  anterior  part  of 
the  column  precedes  the  lateral  inclination  of  the  trunk  which 
first  calls  attention  to  the  deformity.  This  postural  distortion 
becomes  fixed  by  accommodative  changes  in  the  muscles  and 
other  tissues  about  the  spine,  and,  finally,  it  is  confirmed  by 
changes  in  the  shape  of  the  vertebral  bodies  and  by  the  general 
changes  in  the  trunk  as  a  whole.  Thus,  if  one  might  observe 
the  inception  and  development  of  lateral  curvature  of  the  common 
type  he  would  note,  first,  that  the  trunk  was  more  often  flexed  to 
one  side  than  to  the  other,  and  that  this  attitude  gradually  became 
habitual.  Lateral  inclination  of  the  trunk  necessitates,  of  course, 
lateral  deviation  and  rotation  of  the  bodies  of  the  vertebrse,  and 
the  habitual  assumption  of  such  a  posture  implies  disuse  of  other 
postures  and  thus  disuse  of  normal  motion. 

Disuse  of  motion  in  any  direction  is  followed  by  diminished 
power  in  the  inactive  muscles,  and,  as  has  been  stated,  habitual 
deformity  is  followed  by  accommodative  changes  to  a  greater  or 
less  degree  in  the  various  tissues  whose  functions  have  been 
changed  or  modified. 

Thus  the  progress  of  the  deformity  would  be  shown : 

1.  By  the  habitual  assumption  of  an  attitude  simulating 
deformity. 


180  ORTHOPEDIC  SURGERY. 

2.  By  limitation  of  motion  in  the  directions  opposed  to  the 
habitual  attitudes, 

3.  By  fixed  lateral  deviation  of  the  spine  accompanied  by 
rotation  or  twisting  of  the  column. 

One  rarely  has  the  opportunity  to  note  the  development  of 
lateral  curvature,  and  when  patients  are  brought  for  treatment 
fixed  deformity  is  usually  present.  It  is  extremely  difficult  to 
entirely  overcome  fixed  distortion,  while  it  is  comparatively  easy 
to  correct  simple  postural  deformity  in  which  the  secondary 
changes  are  absent  or  but  slightly  advanced.  On  this  account  it 
is  customary  to  divide  lateral  curvature  into  two  classes — the 
true  and  the  false — or  to  speak  of  rotary  lateral  curvature  as 
distinct  from  lateral  curvature.  Thus,  the  term  true  or  rotary 
curvature  would  be  limited  to  those  cases  in  which  the  changes 
are  fixed  and  in  which  cure  is  practically  impossible,  while  false 
or  simple  or  postural  lateral  curvature  would  include  the  early  or 
curable  class.  But  as  the  two  forms  are  simply  stages  in  the 
same  process  it  would  seem  preferable  to  speak  of  the  incipient 
and  the  later  stages  of  lateral  curvature,  or  of  reducible  or 
irreducible  deformity,  the  distinctions  that  are  made  in  classifying 
distortions  of  similar  origin  elsewhere. 

This  point  of  view  is  of  advantage  because  it  relieves  the  sub- 
ject of  much  of  the  obscurity  that  has  resulted  from  this  arbitrary 
division.  It  emphasizes  the  fact,  also,  that  the  habitual  assump- 
tion of  an  improper  attitude  that  simulates  deformity  is  the  first 
step  toward  permanent  distortion,  particularly  in  individuals  who 
by  inheritance  or  by  constitutional  tendency  or  by  occupation  are 
predisposed  to  such  deformity. 

The  Prevention  of  Deformity.  Prevention  includes  the 
avoidance  of  all  the  predisposing  or  exciting  causes  of  weakness 
as  well  as  of  deformity.  These  it  is  hardly  necessary  to  enu- 
merate. 

The  first  and  most  important  preventive  measure  is  the  discov- 
ery of  deformity  or  the  tendency  to  deformity  at  a  time  when  it 
may  be  checked  or  cured.  To  discover  deformity  at  this  period 
of  its  development  one  must  look  for  it,  and  it  would  seem 
that  a  yearly  inspection  at  least  of  the  naked  bodies  of  all  chil- 
dren should  become  a  routine  practice  of  the  family  physican. 
Deformity  in  this  sense  includes  not  only  fixed  distortions,  but 
improper  attitudes  and  postures  of  every  variety  as  well. 

The  importance  of  the  attitude  which  is  habitually  assumed 
during  occupation  has  been  mentioned.     Therefore,  the  provision 


LATERAL  CURVATURE  OF  THE  SPINE. 


181 


of  proper  desks  and  seats  fo7'  school-Ghildren  is  a  very  essential 
part  of  preventive  treatment. 

The  seat  of  the  chair  should  be  deep  enough  to  support  the 
thighs,  yet  it  should  not  interfere  with  flexion  at  the  knees.  It 
should  be  of  such  height  as  to  allow  the  feet  to  rest  firmly  on  the 
floor,  and  it  should  be  inclined  slightly  backward.  The  back  of 
the  chair  should  extend  to  about  the  level  of  the  shoulders ;  it 
should  be  inclined  slightly  backward,  but  arched  somewhat  for- 
ward in  the  lumbar  region  in  order  to  conform  to  the  normal 
lordosis  when  the  child  sits  in  the  erect  posture.  The  desk 
should  be  as  close  to  the  body  as  is  possible,  so  that  the  child 
need  not  lean  far  forward  when  readiug  or  writing.     The  height 


Fig.  98. 


Adjustable  school  desks  and  seats.    Scheiber  and  Klein.    (R6dard.) 


of  the  desk  should  be  slightly  less  than  the  level  of  the  elbows 
when  the  child  sits  erect,  and  the  inclination  should  be  sufficient 
to  hold  the  book  at  the  proper  distance  from  the  eyes  (Figs.  98 
and  99).  The  vertical  handwriting  is  of  advantage  in  that  the 
children  are  taught  to  face  the  desk  squarely,  as  contrasted  with 
the  lateral  twist  of  the  body,  the  usual  attitude  for  writing. 

Treatment.  The  treatment  of  rotary  lateral  curvature  of  the 
spine  does  not  differ  in  principle  from  the  treatment  of  any  other 
weakness  or  deformity,  but  the  application  of  this  principle  is 
difficult  and  the  results  are  far  from  definite  and  satisfactory. 
This  explains,  doubtless,  the  apparently  opposing  theories  and 
met  hods  of  treatment  that  are  still  advocated. 

A  brief  account,  then,  of  the  rules  of  treatment  as  applied  to 


182 


ORTHOPEDIC  SURGERY. 


weakness  in  general  and  of  tlie  exceptions  that  must  be  made  in 
their  application  to  curvature  of  the  spine  may  be  illustrated  by 
comparing  this  deformity  with  another  of  similar  causation. 

One  may  take  for  comparison  the  weak  foot,  since  the  foot 
corresponds  more  nearly  to  the  spine  than  does  a  simple  joint, 
because  of  the  number  of  bones  of  which  it  is  made  up.  In  the 
treatment  of  the  weak  foot  one  must  first  overcome  all  restrictions 
to  passive  motion,  even  by  force,  if  this  be  necessary.  One  next 
endeavors  to  strengthen  the  muscles  that  support  the  foot,  by 


Fig.  99. 


Adjustable  school  seat.    (Miller  and  Stone.) 


appropriate  exercises,  particularly  those  whose  action  is  opposed 
to  the  habitual  deformity.  The  avoidance  of  improper  attitudes 
and  of  overfatigue  that  favor  deformity  is  also  essential.  Finally, 
if  persistent  deformity  makes  it  evident  that  the  voluntary  or 
natural  efforts  of  the  patient  are  inefficient,  a  brace  is  employed 
to  support  the  foot  in  proper  position  in  order  to  aid  the  weakened 
muscles  and  to  hold  the  joints  in  the  normal  position  in  which 
they  may  work  to  advantage.  Under  these  conditions  one  would 
expect  an  immediate  relief  of  discomfort  and  a  progressive  trans- 
formation of  the  internal  structure  of  the  foot,  which  in  favorable 


LATERAL  CURVATURE  OF  THE  SPINE.  183 

cases  would  lead   to  complete  cure  of  the  deformity  and  of  the 
weakness  as  well. 

The  principles  of  the  treatment  of  any  variety  of  weakness  not 
directly  jnduced  by  disease  are,  then : 

1.  To  overcome  all  restriction  to  passive  motion. 

2.  To  strengthen  the  weakened  muscles,  especially  those  whose 
action  is  opposed  to  habitual  deformity. 

3.  To  insist  on  the  avoidance  of  overfatigue  and  improper 
postures. 

4.  To  support  the  weak  part  by  a  brace  if  deformity  cannot 
be  prevented  otherwise. 

In  applying  these  principles  to  the  treatment  of  the  distorted 
spine  the  first  step,  the  removal  of  restriction  to  passive  motion 
in  all  directions,  is  difficult  because  of  the  variety  of  muscles  and 
other  tissues  that  may  have  become  involved,  and  because  the 
bodies  of  the  vertebrae  lying  within  the  trunk,  of  which  the  dis- 
tortion is  always  greater  than  of  the  spinous  processes,  can 
be  only  indirectly  affected  by  voluntary  or  by  passive  move- 
ments. 

The  cultivation  of  the  muscular  system,  and  particularly  of 
those  muscles  whose  action  is  opposed  to  the  habitual  deformity, 
is  the  second  indication  in  treatment.  As  applied  to  the  treat- 
ment of  the  weak  foot  in  which  the  adductor  and  extensor  muscles 
are  at  fault,  this  treatment  is  simple,  but  as  applied  to  the  trunk 
it  is  difficult,  because  there  are  in  nearly  all  developed  cases  two 
curves,  the  one  primary  and  the  other  secondary,  in  direction 
directly  opposed  to  one  another.  These  opposing  curves  are 
supplied  in  great  part  by  the  same  muscles,  and  it  is  difficult  by 
voluntary  effort  to  straighten  the  convexity  of  one  without  at  the 
same  time  increasing  that  of  the  other. 

The  third  principle  in  treatment  is  the  avoidance  of  predispos- 
ing attitudes  and  of  overwork.  This  again  may  be  more  easily 
applied  to  the  treatment  of  the  weak  foot ;  first,  because  it  is 
relieved  from  strain  when  the  sitting  posture  is  assumed,  and 
because  active  use,  as  in  walking,  may  be  utilized  as  an  exercise 
for  strengthening  the  muscles.  But  the  muscles  of  the  trunk  are 
not  exercised  to  any  extent  in  ordinary  walking,  which  is  for 
many  individuals  the  only  form  of  activity,  nor  is  the  spine 
relieved  from  weight  when  the  patient  is  seated.  On  the  con- 
trary, it  is  in  this  restful  attitude  that  the  deformities  of  the  spine 
are  usually  most  marked.  Thus,  only  in  the  recumbent  attitude 
is  the  spine  entirely  relieved  from  strain,  and  even  at  such  times 


184  OR THOPEDIC  S UB GEE  Y. 

the  deformities  may  be  favored  by  the  habitual  attitudes  of  the 
patient. 

The  weak  foot  can  be  supported  by  a  brace,  which  does  not  in- 
terfere with  its  activity,  but  which,  on  the  contrary,  aids  normal 
motion  by  holding  the  bones  in  proper  relation  to  one  another. 
But  in  the  treatment  of  the  spine  the  conditions  are  quite  differ- 
ent, since  the  back  cannot  be  supported  without  at  the  same 
time  restraining  its  normal  motion.  Finally,  no  brace  applied 
to  the  trunk  is  efficient,  for  while  it  may  prevent  the  lateral 
deviation  it  can  exercise  little  direct  action  in  overcoming  the 
rotation  of  the  spinal  column. 

This  comparative  method  of  exposition  has  been  adopted  in 
order  to  illustrate  the  fact  that  it  is  not  the  difficulty  of  formu- 
lating principles,  but  the  difficulty  of  applying  them  that  makes 
the  therapeutics  of  rotary  lateral  curvature  of  the  spine  perplex- 
ing. In  practice  one  must  recognize  the  limitations  of  all  systems 
of  treatment  as  applied  to  this  particular  deformity,  and  select 
and  combine  methods  that  may  be  most  applicable  to  the  par- 
ticular case  under  treatment. 

For  example,  in  the  treatment  of  rhachitiG  scoliosis  in  a  young 
child  one  cannot  count  upon  the  voluntary  assistance  of  the 
patient ;  therefore,  treatment  by  simple  gymnastic  exercises  is 
impracticable.  In  this  class  of  cases  forcible  correction  of  the 
deformity  and  retention  by  the  use  of  apparatus,  combined  with 
massage,  and  even  the  removal  of  superincumbent  weight  by 
recumbency  would  be  the  treatment  of  selection.  At  this  age  the 
trunk  is  flexible  and  the  deformity  may  be  progressively  reduced 
by  forcible  manipulation,  followed  by  fixation  of  the  trunk  in  the 
improved  position.  By  such  means  one  may  expect  at  this  period 
of  rapid  growth  to  induce  a  transformation  of  the  deformed  verte- 
bral bodies  to  an  approximation  at  least  of  the  normal.  In  such 
cases  the  correction  of  the  underlying  deformity  of  the  bones  which 
must  almost  inevitably  increase  with  the  growth  of  the  patient 
would  quite  outweigh  the  disadvantage  of  depriving  the  muscles 
of  their  normal  stimulus  during  the  corrective  period  of  treatment. 

In  the  ordinary  type  of  scoliosis  in  older  subjects,  particularly 
if  the  distortion  is  moderate  in  degree  and  the  changes  in  the 
bones  but  slight,  one  would  expect  to  attain  the  best  result  by 
gymnastic  training  and  by  regulation  of  the  postures.  Although 
even  in  this  class  supports  may  be  of  service,  if  by  such  means 
the  trunk  may  be  held  in  an  overcorrected  attitude  until  the 
deformity  habit  is  overcome. 


LATERAL  CUBVATUBE  OF  THE  SPLNE.  185 

The  advisability  of  a  change  of  occupation  has  been  mentioned. 
It  is  probable  that  if  the  patient  with  incipient  or  even  more 
pronounced  curvature  of  the  spine  were  removed  from  school, 
were  transferred  to  the  country  where  during  the  succeeding  years 
of  childhood  and  adolescence  much  of  the  time  might  be  passed 
in  active  exercise  in  the  open  air,  the  final  result  would  compare 
very  favorably  with  that  attained  by  active  treatment  under  less 
favorable  circumstances.  Such  complete  change  of  occupation 
and  surroundings  is,  of  course,  impracticable  in  most  instances. 
Lateral  curvature  of  the  spine  is  not  a  serious  disease,  it  is  simply 
an  insidious  distortion  which  rarely  causes  more  than  compara- 
tively slight  discomfort.  It  is  usually  overlooked  in  the  incipient 
stage  when  it  might  be  checked  or  cured,  and  when  the  deformity 
finally  attracts  attention  it  is  often  no  longer  amenable  to  cor- 
rection. Under  these  circumstances,  with  the  uncertainty  that 
exists  as  to  the  ultimate  prognosis,  the  tediousness  of  treatment 
which  cannot  offer  the  assurance  of  definite  cure,  it  is  not  strange 
that  the  affection  is  not  one  for  the  treatment  of  which  any  con- 
siderable sacrifice  is  considered  essential. 

A  third  class  of  cases  would  include  the  fixed  deformity  in  older 
sitbjects,  many  of  whom  are  obliged  to  assume  in  their  occupations 
attitudes  that  predispose  to  deformity.  In  the  treatment  of  this 
class  a  support  to  relieve  discomfort  and  to  prevent  exaggerated 
distortion  may  be  essential. 

Thus,  there  are  three  classes  or  types  of  scoliosis  in  which 
distinct  methods  of  treatment  may  be  employed. 

1.  Curvatures  in  very  young  children,  in  which  forcible  cor- 
rection and  fixation  are  indicated  in  the  hope  of  correcting  the 
deformity  of  the  bones  and  curing  the  distortion. 

2.  The  milder  degrees  of  deformity  for  which  treatment  by 
exercises  and  if  possible  by  favoring  postures  is  that  of  selection, 
and  in  which  support  is  a  temporary  and  incidental  jidjunct. 

3.  The  third  class  would  include  fixed  deformity  in  older  sub- 
jects as  well  as  those  cases  caused  by  disease ;  as,  for  example, 
by  paralysis,  by  empyema  and  the  like,  for  which  constant  sup- 
port might  be  required. 

As  a  rule,  however,  no  absolute  therapeutic  distinction  can  be 
made,  and  treatment  by  exercises  and  by  postures  should  be 
employed  whenever  practicable  in  all  cases,  whether  supports  are 
used  or  not. 

Posture  and  Exercises.  Whatever  may  have  been  the  original 
cause  of  the  distortion   of  the  spine  and   whatever  may  be  its 


186  OB  THOPEDIC  S  UB  QEB  Y. 

degree  it  is  more  marked  when  the  patient  is  fatigued.  Fatigue 
in  the  normal  individual  is  shown  by  the  increase  in  the  normal 
anteroposterior  curves  ;  fatigue  in  the  deformed  subject  causes  an 
increase  in  the  pathological  curves.  It  requires  far  more  mus- 
cular effort  to  hold  the  deformed  spine  in  the  best  possible  attitude 
than  to  hold  the  normal  spine  in  the  correct  posture.  Motion  in 
the  normal  spine  is  as  free  in  one  direction  as  in  another,  and  it 
simply  requires  a  proper  balancing  of  the  muscular  force  to  hold 
it  in  the  median  line.  Under  the  influence  of  fatigue  it  has  no 
more  inclination  toward  one  side  than  the  other  unless  the  occu- 
pation or  the  attitude  of  the  patient  influences  it.  But  when 
there  is  a  fixed  deformity,  to  overcome  which,  even  in  part, 
requires  the  conscious  effort  of  the  patient,  it  is  evident  that  on 
the  relaxation  of  this  effort  the  spine  will  sink  back  into  the 
habitual  posture.  The  more  confirmed  the  deformity  the  greater 
must  be  the  effort  to  overcome  it,  and  the  more  rapidly  wil] 
fatigue  be  manifest.  Fatigue,  or,  rather,  the  relaxation  of  con- 
scious muscular  effort,  is  favored  by  attitudes  that  do  not  require 
the  balancing  action  of  the  muscles.  For  example,  the  sitting 
posture  during  school  hours  favors  deformity,  while  the  constant 
alternation  qi  postures  in  work  or  play  that  requires  muscular 
activity  opposes  it.  Thus,  the  selection  of  occupations,  or,  at 
least,  the  restriction  of  the  time  passed  in  inactive  postures,  is  an 
important  part  of  treatment. 

As  improper  attitudes  are  favored  by  weakness  of  muscles  and 
as  the  maintenance  of  the  best  possible  position  requires  a  greater 
expenditure  of  muscular  force  than  is  required  in  the  normal 
individual,  the  strengthening  of  all  the  muscles  of  the  body,  and 
particularly  of  those  of  the  back,  by  gymnastic  exercises,  even 
beyond  the  normal  standard,  is  the  most  important  indication  in 
treatment. 

One  of  the  most  effective  systems  of  treatment  of  lateral  curva- 
ture is  that  advocated  by  Teschner,  of  New  York.  On  the  theory 
that  lateral  curvature  is  induced  by  or  that  its  development  is 
favored  by  a  general  lack  of  muscular  strength  and  lack  of  mus- 
cular control  and  co-ordination,  Teschner  urges  the  necessity  of 
the  systematic  cultivation  of  all  the  muscles  of  the  body  as  well 
as  those  of  the  trunk,  the  part  particularly  at  fault.  He  also 
insists  upon  the  importance  of  exercising  each  muscular  group  to 
the  point  of  fatigue  on  the  theory  that  a  muscle  cannot  be 
developed  to  its  full  capacity  unless  it  is  thoroughly  fatigued  by 
uninterrupted  automatic  contractions  and  relaxations.     The  term 


LATERAL  CURVATURE  OF  THE  SPINE. 


187 


automatic  implies  that  the  patient  shall  be  so  thoroughly  trained 
in  the  rhythmical  movements  that  they  require  no  thought  for 
their  performance.  Thus,  ease  and  grace  may  replace  awkward- 
ness and  inco-ordination. 

The  system  advocated  by  Teschner  is  modified  from  one  taught 
by  Attilla,  a  "trainer  of  strong  men."  It  consists  of  a  series  of 
exercises  with  light  dumb-bells,  and  it  is  followed  by  so-called 
heavy  work.  The  exercises  are  designed  for  systematic  cultiva- 
tion of  all  the  muscles  of  the  body,  the  heavy  work  more  directly 
for  the  correction  of  the  deformity  of  the  spine. 

General  Exercises.  The  exercises  should  be  performed  before 
a  mirror,  the  patient  being  clad  in  a  close-fitting  rowing  suit,  so 


Fig.  100. 


Fir.  102. 


that  the  attitudes  may  be  constantly  observed  by  the  patient  and 
by  the  instructor.  The  greatest  attention  is  paid  to  the  perfection 
of  the  alternating  movements  of  the  limbs  in  order  that  they  may 
become  in  time  purely  automatic  in  character.  During  the  per- 
formance of  the  exercises  the  patient  holds  himself  in  the  best 
possible  position. 

These  exercises  were  described  and  illustrated  by  Teschner  in 
the  Annah  of  fiurgery  for  August,  1895,  from  which  they  are, 
with  his  permission,  reproduced. 

"A  pair  of  dumb-bells,  weighing  from  one-half  to  five  pounds 
each,  according  to  tlie  ability  of  the  patient,  is  used  in  a  series  of 
twenty-six  exercises. 


188 


ORTHOPEDIC  S  UB GER  Y. 


"  The  Exercises.  The  patient  stands  erect,  the  heels  together, 
the  toes  apart,  the  knees  thoroughly  extended,  the  abdomen 
retracted,  the  chest  high,  the  head   well   poised,  and  the  patient 


Fir    104. 


Fig.  105. 


Fig.  10(>. 


,^-...- 


luoking  intently  and  sharply  into  his  or  her  own  eyes  in  the 
mirror,  the  lips  being  evenly,  but  not  too  firmly,  closed,  and  the 
facial  muscles  in  repose.  The  patient  should  breathe  easily  and 
regularly  while  exercising  (Figs.  100  and  101). 


LATERAL  CURVATURE  OF  THE  SPINE. 


189 


"  1.  The  upper  extremities  are  fully  extended  downward,  the 
forearms  supinated,  the  elbows  remaining  close  to  the  sides  of  the 


Fig.  107. 


Fig.  in,". 


Fig.  109. 


Ftr.  no. 


body,  and  the  up]Der  arms  being  fixed  ;  the  forearms  are  alternately 
and    automatically  fully  flexed    and    extended,   the   wrists    and 


190 


ORTHOPEDIC  SUROEBY. 


entire  body  being  fixed  and  immovable.  Twenty  to  fifty  times 
(Fig.  102). 

"  2.  The  same  position  and  exercise,  except  that  the  forearms, 
are  fully  pronated,  and  remain  so  during  alternate  flexion  and 
extension.     Twenty  to  fifty  times  (Fig.  103). 

"3.  Both  bells  over  the  shoulders,  the  arms  abducted  at  right 
angles  to  the  body  and  in  the  same  vertical  and  horizontal  planes, 
the  forearms  fully  flexed  upon  the  arms,  and  the  wrists  fully 
flexed  upon  the  forearms.  The  forearms  and  wrists  are  then 
alternately  and  automatically  extended  and  flexed.  Ten  to 
twenty  times  (Fig.  104). 


"  4.  The  same  position  and  exercise,  except  that  both  upper 
extremities  are  flexed  and  extended  at  the  same  time.  Five  to 
fifteen  times  (Fig.  105). 

"  5.  Both  upper  extremities  fully  extended  forward  on  a  level 
with  the  shoulders,  the  dorsum  of  the  hands  outward.  They  are 
then  fully  and  forcibly  abducted  on  a  horizontal  plane,  the  patient 
at  the  same  time  raising  the  body  upon  the  toes,  and  are  then 
permitted  to  recede  to  the  original  position,  the  body  resting  on 
the  toes  and  heels,  the  elbows  and  wrists  still  rigid,  the  bells 
not  being  permitted  to  touch  as  they  approximate  each  other. 
Five  to  ten  times  (Figs.  106  and  107). 

"  6.  Bells  in  the  position  of  exercises  No.  3  and  No.  4.     The 


LATERAL  CURVATURE  OF  THE  SPINE. 


191 


arms  are  fully  extended  alternately  above  the  head.  Ten  to 
twenty  times  (Fig.  108). 

"  7.  Bells  in  front  of  the  thighs,  forearms  pronated,  and  bells 
alternately  raised  to  the  level  of  the  shoulders,  the  elbows  and 
wrists  being  fixed.      Ten  to  twenty  times  (Fig.  109). 

"  8.  The  arms  abducted  at  right  angles  to  the  body,  the  bells 
rotated  rapidly  and  forcibly  forward  and  backward,  the  elbows 
being  fixed.     Five  to  ten  times  (Fig.  110). 

"  9.  The  arms  abducted  at  right  angles  to  the  body,  the  thumbs 
upon  one  ball  of  each  bell,  the  hands  circumducted  forward  from 


Fig.  113. 


Fig.  114. 


Fig.  115. 


above  downward,  the  ball  upon  which  the  thumbs  rest  describing 
circles,  the  elbows  and  shoulders  being  fixed.  Five  to  ten  times 
(Fig.  111). 

"  10.  The  same  as  No.  9,  the  hands  being  circumducted  back- 
ward.    Five  to  ten  times  (Fig.  111). 

''11.  The  bells  to  the  side.  Right  face  upon  left  heel,  then 
placing  the  foot  at  right  angles  to  right  foot  opposite  the  arch, 
the  knees  slightly  fiexed,  the  right  hand  at  waist-line  against 
the  body,  the  bell  being  perpendicular.  Second  part  of  motion : 
strike  from   the  shoulder  to  level  of  the  face,  advancing  a  step 


]92 


ORTHOPEDIC  SURGERY. 


upon  the  left  foot,  rapidly  extending  the  right  thigh  and  leg,  tlie 
right  foot  being  fixed  upon  the  floor,  and  quickly  back  to  position. 
Ten  to  fifteen  times  (Figs.  112  and  113). 

"  12.  Exactly  the  reverse  of  No.  11.     Ten  to  fifteen  times. 

"  13.  Bells  extending  above  the  head,  palmar  surfaces  looking 
forward,  bending  down  to  the  floor,  the  knees  remaining  extended, 
and  return.     Five  to  fifteen  times  (Figs.  114  and  115). 

"  14.  Bells  downward  at  the  sides,  raising  and  dropping  the 
shoulders.     Ten  to  twenty  times  (Fig.  116). 

"  15.  Bells  downward  at  the  sides,  flexing  the  spine  laterally, 
first  to  the  right  and  then  to  the  left.  Ten  to  twenty  times 
(Fig.  117). 


Fig.  116. 


Fig.  117. 


"  16.  Both  arms  are  extended  forward  to  about  forty-five 
degrees  and  abducted  at  about  the  same  angle,  then  forcibly 
crossed  in  front  of  the  chest,  causing  the  pectoral  muscles  to  con- 
tract vigorously,  the  elbows  and  wrists  being  fixed,  and  then  back 
to  the  original  position.  Five  to  twenty  times,  alternating  the 
right  and  left  hands  above  (Fig.  118). 

"17.  Bells  at  the  sides,  palmar  surfaces  looking  forward. 
Extend  arms  backward  in  a  vertical  plane  as  forcibly  as  possible, 
holding  them  rigid  in  the  fully  extended  position  for  a  few 
moments,  and  then  returning  the  bells  to  the  sides.  Five  to 
fifteen  times  (Figs.  119  and  120). 


LATERAL  CURVATURE  OF  THE  SPINE. 


193 


"18.    Bells  to  the  sides.     Raise  the  body  upon  the  toes  and 
sink  to  the  original  position.     Ten  to  twenty  times  (Fig.  121). 


Fig.  118. 


Fig.  119. 


Fig.  120. 


Fig.  121. 


"19.  Same  position.     Eaise  the  toes  as  far  as  possible  from 

the  floor,  the  body  remaining  erect.  Ten  to  twenty  times  (Fio-. 

122).  J             \     ^ 

13 


194 


ORTHOPEDIC  SUBQEBY. 


*'  20.  Same  position.  The  patient  squats,  abducting  the  knees 
and  resting  upon  the  toes,  the  heels  being  raised,  the  trunk  per- 
fectly erect,  then  resuming  first  position.  Five  to  twenty  times 
(Fig.  123). 


Fig.  122. 


Fig.  123. 


Fig.  124. 


Fig.  125. 


"21.  Same  position.      Standing  upon  left  foot.      Flexing  the 
right  thigh  to  a  right  angle  to  the  body,  extending  the  knee  and 


LATERAL  CURVATURE  OF  THE  SPINE. 


195 


ankle  fully.  The  patient  squats  on  the  left  ham,  the  left  heel 
reraaiuing  on  the  floor,  and  then  resumes  the  first  position.  Two 
to  five  times  (Fig.  124). 

"  22.  The  same   standing  upon  the  right  foot.     Two   to  five 
times. 

Fig.  126.  Fig.  127. 


"  23.  The  same  position.  Alternately  and  forcibly  flexing  the 
thighs  and  legs,  causing  the  knees  to  touch  the  shoulders.  Ten 
to  twenty  times  (Fig.  125). 


Fig.  128. 


/ 


X.,.    : 


"  24.  The  same  position  as  in  No.  21,  extending  the  right 
lower  extremity,  the  right  bell  inside  the  thigh,  the  right  foot 
moved  in  a  circle  on  a  horizontal  plane  to  complete  extension 
backward,  and  resuming  the  first  position.  Two  to  five  times 
(Figs.  120  and  127). 


196  ORTHOPEDIC' SURGERY. 

"  25.  The  same  as  No.  24,  standing  upon  the  right  foot.  Two 
to  five  times  (Figs.  126  and  127). 

''26.  The  patient  lying  supine  upon  the  floor,  the"^  lower 
extremities  fully  extended,  the  bells  resting  upon  the  chest,  then 
raising  the  trunk  to  the  sitting  position,  the  lower  extremities 
remaining  extended,  and  the  eyes  being  fixed  upon  the  ceiling, 

Pig.  ]29. 


Scoliosis  of  an  advanced  type  accompanied  by  dyspnoea  and  cyanosis.    (Teschner.) 

and  returning  to  the  original  position,  touching  the  back  of  the 
head  only  on  the  floor ;  thus  the  hyperextension  of  the  spine  is 
maintained.     Five  to  twenty  times  (Fig.  128)." 

I  consider  these  floor  exercises  especially  useful,  and,  in  prac- 
tice, add  several  others  to  those  described  by  Teschner,  viz. : 

27.  The  patient  lying  as  in  Fig.  128,  lifts  each  fully  extended 
leg  alternately  a  distance  of  about  two  feet  from  the  floor,  then 
lets  it  slowly  sink  to  its  original  position.     Ten  times. 


LA  TEE  AL   CURVATURE  OF  THE  SPINE.  1 9  7 

28.  Both  limbs  together.     Five  times. 

29.  The  patient  lying  extended  in  the  prone  position,  places 
the  palms  of  the  hands  on  the  hips  and  "looks  at  the  ceiling/' 
overextends  the  spine  as  much  as  possible,  then  sinks  slowly  to 
the  original  position. 

Fig.  130. 


The  same  patient  swinging  30-pound  bell,  showing  the  muscular  development.    (Teschner.) 

oO.  Each  leg  fully  extended  is  lifted  upward  alternately  as  far 
as  possible  (hyperextension  at  the  hif)s).     Ten  times. 

31.  Hyperextension  at  both  hips  simultaneously  if  possible. 
Five  times. 

"  When  the  i)atiojit  has  become  proficient  in  these  exercises, 
they  should  he  done  at  home  every  morning  and  evening. 


198 


ORTHOPEDIC  SURGERY. 


"  The  Heavy  Work.  Bells,  weighing  from  five  to  eighty 
pounds  each,  and  steel  bars  and  bar-bells,  weighing  from  twenty- 
six  to  over  one  hundred  and  eleven  pounds,  are  used  in  dijBPerent 
ways.  Bells  are  pushed  from  the  shoulders  above  the  head  alter- 
nately as  often  as  the  patient  is  able  (Figs.  131  and  132). 


Fig.  131. 


Fig.  132. 


The  patient  pushing  25-pound  bells  ; 
the  right  arm  up.    (Teschner.) 


The  patient  pushing  2.5-pound  bells ; 
the  left  arm  up.    (Teschner.) 


"The  patient  is  instructed  to  swing  a  heavy  bell  with  one 
hand  from  the  floor  above  the  head  and  down  again,  the  elbow 
and  the  wrist  being  fixed,  and  the  motion  repeated  as  often  as 
possible  in  a  systematic  manner;  then  with  the  other  hand  the 
same  number  of  times  and  later  with  both.  This  exerts  all  the 
extensor  muscles  from  the  toes  to  the  head  in  rapid  succession. 


LATERAL  CURVATURE  OF  THE  SPINE.  199 

(For  this  exercise  the  patient  stands  firmly,  with  the  legs 
astride  of  the  heavy  bell,  and  then,  bending  over,  he  seizes  it 
and  throws  the  extended  arm  upward  entirely  by  the  action  of 
the  back  muscles.  The  bell  is  poised  for  a  moment  above  the 
head,  and  it  is  then  swung  downward,  carrying  the  extended  arm 
between  and  behind  the  legs.) 

"  When  a  heavy  bell  is  pushed  or  swung  above  the  head  on 
the  side  opposite  the  scoliosis,  the  action  of  the  back  muscles,  to 
sustain  the  weight  and  equilibrium,  is  such  as  to  cause  the  curved 
spine  to  approximate  a  straight  line  (Fig.  132).  A  similar  result 
is  produced  when  a  heavy  weight  is  held  by  the  side  of  the  erect 
body  on  the  scoliotic  side,  the  arm  being  at  full  length. 

"  When  a  heavy  bar  is  raised  above  the  head  with  both  hands 
the  patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  main- 
tain an  equilibrium.  This  necessitates  the  bending  of  the  head 
backward,  the  straightening  and  hyperextending  of  the  spine, 
and  consequently  correcting  a  faulty  position  with  a  weight  super- 
imposed. The  heavier  the  weight  put  above  the  head,  whether 
with  one  hand  or  with  two,  the  more  the  patient  must  exert 
himself  or  herself  to  attain  and  maintain  a  correct  or  an  im- 
proved attitude  in  order  to  sustain  the  equilibrium.  (By  an 
improved  attitude  I  mean  the  greatest  amount  of  correction  of 
the  deviation  of  the  spine  that  the  fixation  of  a  deformity  will 
allow  of.)  Hence,  the  greater  the  weight,  the  more  forcible  the 
actions  of  the  muscles  become,  and  the  greater  the  temporary 
reduction  of  a  deformity.  It  is  by  means  of  frequent  and 
forcible  temporary  reductions  of  deformities,  by  voluntary  mus- 
cular action,  that  we  can  hope  to  improve,  and  do  improve,  those 
cases  which  are  amenable  to  any  form  of  active  treatment. 

"  When  a  patient,  lying  supine  upon  the  floor,  raises  a  heavy 
bar  above  the  head  so  that  the  arms  are  perpendicular  to  the 
flooi',  the  weight  of  the  bar,  the  position  and  weight  of  the  body, 
and  the  action  of  the  muscles  tend  to  broaden  the  entire  back 
and  shoulders,  and  a  slow  downward  movement  tends  to  widen 
the  entire  chest,  and  most  markedly  at  the  shoulders.  The  fre- 
quent repetition  of  the  upward  and  downward  movements  plays 
an  important  part  in  the  rapid  development  of  the  chest  and 
back.  Pushing  the  bells  above  the  head,  swinging  them  with 
each  hand  separately  and  with  both  hands  together,  raising  a  bar 
above  the  head,  standing  and  lying  down,  and  the  exercises 
before  enumerated,  constitute  one  day's  work. 

"As   the   amoiuit   of   work    performed   by   a  patient   depends 


200 


ORTHOPEDIC  SURGERY. 


upon  the  last  previous  record  of  that  patient,  that  record  must  be 
improved  upon  at  each  succeeding  visit,  unless  there  be  a  good 
reason  to  the  contrary.  Most  patients  can  well  stand  three 
treatments  a  week  (vide  table).  In  mild,  habitual  cases  im- 
provement in  deportment  is  noticed  by  the  patient's  relatives 
and  friends  and  by  the  patients  themselves  within  the  first  two 
weeks.  In  these  cases  two  months'  treatment  usually  suffices  to 
effect  a  '  complete '  cure.  In  the  more  severe  cases  such  rapid 
results  cannot  be  expected,  but  a  certain  appreciable  improvement 
is  effected,  and  the  amount  of  improvement  depends  upon  the 
persistent  continuance  of  the  treatmeat.  When  there  is  fixed 
rotation  of  long  standing,  with  bony  and  ligamentous  changes, 
the  prospects  are  not  so  good  ;  but  even  in  those  cases  consid- 
erable improvement  will  be  evident." 

"  Patients  are  not  permitted  to  wear  supports  of  any  kind,  not 
even  corsets.  They  should  not  exercise  until  at  least  two  hours 
after  a  meal,  nor  when  menstruating.  The  general  health  is 
improved  by  the  exercises ;  the  patients  gain  in  height  and 
weight.  The  girth  and  breadth  measurements,  chest  depth, 
strength  tests,  and  lung  capacity  are  generally  increased,  and  the 
depth  of  the  abdomen  is  usually  decreased.  In  some  cases,  es- 
pecially those  of  undersized  patients,  the  increase  in  height  is 
very  rapid,  and  it  is  certainly  more  than  the  increase  by  ordinary 
growth.  There  were  marked  cases  of  flat  foot  which  were  bene- 
fited. The  flat  feet  became  shorter  through  the  exercises  by  the 
increase  in  depth  of  the  inner  arches." 

Record  of  the  Work  Performed  by  a  Girl  Fourteen  Years 
OF  Age  (Teschner). 


Regu- 

Swinging 

Swinging 
with  both 
hands  two 
15-lb.  bells. 

50-lb.  bar  above  the 

Diite 

lar 

Pushiner 

with  each 

Pushing 

head. 

1895.' 

exer- 
cises. 
Bells. 

two  10-1  b. 
bells. 

hand  one 
15-lb.  bell, 
right  to  left 

two20-lb. 
bells. 

Standing.!      ^f. 

April  6 

31bs. 

"      9 

100 
150 

10-10 
25-25 

5 
15 

Instructed. 
2 

Instructed. 

"    11 

io 

5 

2  15-lb.bells 

120- lb.  bell 

"    13 

50 

25-25 

25 

12 

5 

10 

"    16 

54 

30-30 

35 

18 

7 

12 

"    18 

60 

35-35 
1  25-1  b.  bell 

40 
2  20-lb.bells 

20 

7 

15 

"     20 

70 

20-20 

20 

30 

10 

15 

"     25 

90 

22-22 

25 

33 

15 

16 

"     27 

100 

35-35 

30 

50 

17 

20 

"     30 

110 

50-50 

35 

60 

20 

22 

May     2 

120 

60-60 

36 

70 

20 

25 

I  30-lb.  bell 

2  25  lb.  bells 

64-lb.  bar 

64-lb.  bar 

"      4 

140 

20-20 

40 

25 

5 

10 

"       7 

1.50 

25-25 

45 

30 

7 

12 

"     14 

160 

27-27 

50 

34 

9 

13 

'•     16 

170 

30-30 

55 

40 

10 

14 

LA  TEBAL  C UR  VA T URE  OF  THE  SPINE.  20 1 

This  system  of  exercises  combines  the  forcible  correction  of 
deformity  and  the  overcoming  of  restriction  of  normal  motion  by 
means  of  the  "  heavy  work  "  with  muscle  building.  It  has  the 
merit  also  of  making  an  immediate  mental  impression  upon  the 
patient  which  no  other  system  can  make  ;  for  if  the  patient  does 
not  "  strain  every  nerve  "  he  must  certainly  exercise  every  muscle 
to  preserve  the  equilibrium  while  supporting  the  heavy  weights, 
and  this  mental  impression  is,  undoubtedly,  one  of  the  important 
elements  in  successful  treatment. 

The  system  has  the  disadvantage,  if  disadvantage  it  may  be 
called,  of  making  class  work  impossible,  for  the  patient  must  be 
under  constant  supervision,  not  only  that  he  may  be  urged  to 
the  limit  of  his  capacity,  but  that  overstrain  may  be  avoided  as 
well. 

It  might  appear  from  the  description  that  the  danger  of  over- 
work is  great,  but  in  a  long  series  of  cases,  some  of  which  were 
complicated  by  defects  of  the  heart  and  lungs,  no  unfavorable 
symptoms  have  been  observed  by  Teschner.  The  system  is, 
however,  one  that  can  only  be  practised  by  a  physician. 

Another  system  of  exercises,  modified  somewhat  from  the 
so-called  Swedish  system,  more  suitable  for  class  work  is  that 
followed  at  the  Hospital  for  Ruptured  and  Crippled.  Dr. 
Truslow  has  been  kind  enough  to  outline  for  me  some  of  the 
more  important  exercises,  and  to  illustrate  them  with  the  photo- 
graphs that  are  reproduced  here. 

The  objects  of  the  treatment  are:  (1)  To  overcome  the 
patient's  faulty  habits  of  posture  by  the  repeated  purposeful 
assumption  of  proper  postures  ;  in  other  words,  to  counteract  the 
deformity  habit  by  training  the  mental  and  muscular  perception 
of  symmetry.  (2)  To  stimulate  and  to  strengthen  the  weakened 
muscles,  particularly  those  muscular  groups  that  are  especially 
concerned  in  overcoming  the  deformities,  and  which,  for  the 
present  purpose,  may  be  considered  as  weak. 

For  convenience  of  description  the  exercises  are  divided  into 
two  classes  :     (1)  self-correction  ;  (2)  muscle  building. 

Self-correction,  Postures.  The  first  exercises  («  and  b)  in  self- 
correction  are  for  the  purpose  of  overcoming  the  anteroposterior 
deformities  that  usually  accompany  lateral  deviation  of  the 
spine. 

{a)  Heaj>  Bending  Backward.  In  this  exercise  the  chin  is 
not  tilted  upward,  but,  the  head  being  held  level,  the  neck  is 
drawn  dir(,'<;tly  backward  until  the  cervical  and  upper  part  of  the 


202  OB THOPEDIC  SUBGEB Y. 

dorsal  segments  of  the  spine  are  completely  extended.  Thus, 
by  increasing  the  distance  between  the  points  of  attachment  of 
the  sternomastoids  and  the  scaleni,  strong  traction  is  made  upon 
these  muscles  with  the  effect  of  elevating  the  upper  part  of  the 
thorax — an  important  feature  in  the  exercise. 

(6)  Trunk  Bending  Forward  and  Trunk  Raising.  The 
patient  stands  in  the  erect  posture  with  the  spine  extended  and 
the  chest  expanded  as  in  the  previous  exercise.  The  trunk  is 
then  bent  forward  (similar  to  Fig.  138),  the  only  motion  being 
at  the  hip-joints.  The  trunk  is  then  raised  again  to  the  former 
position,  care  being  taken  to  keep  the  hips  farther  back  than  the 
chest.  In  both  flexion  and  extension  the  spine  must  be  rigidly 
held  in  the  corrected  attitude,  and  there  must  be  no  motion  at  the 
knees.  There  is,  of  course,  a  movement  corresponding  to  exten- 
sion at  the  ankle-joints  when  the  legs  and  buttocks  are  thrown 
backward  to  compensate  for  the  forward  bending  of  the  body. 
The  object  of  this  exercise  is  to  train  the  patient  to  keep  the  hips 
back  and  the  chest  forward. 

The  other  exercises  in  self-correction  are  for  the  purpose  of 
overcoming  lateral  deviation  of  the  spine,  the  right  dorsal,  left 
lumbar  curve  being  taken  as  the  type  (Fig.  133). 

This  series  is  arranged  in  a  progression,  and  each  one  must  be 
learned  before  the  next  in  order  is  attempted. 

(c)  Left  Neck  Firm.  The  left  hand  is  placed  behind  the 
neck,  the  left  shoulder  is  raised,  and  the  left  elbow  is  held  well 
back.  This  posture  impresses  upon  the  patient  the  necessity  of 
approximating  the  left  shoulder  and  the  neck  (Fig.  134). 

(rf)  Body  Inclination  to  the  Left.  This  is  a  most  impor- 
tant posture ;  it  is  intended  to  correct  mechanically  the  faulty 
inclination  to  the  right  and  to  overcome  the  upper  curve  by  trac- 
tion on  its  concavity.  The  patient  holding  the  arm  in  the  first 
position  is  instructed  to  stretch  well  out  with  the  left  elbow, 
rotating  upward  and  abducting  the  left  scapula  as  much  as  pos- 
sible. This  puts  upon  the  stretch  the  rhomboidei  and  the  lower 
half  of  the  trapezius  of  the  left  side,  thus  making  strong  traction 
upon  their  points  of  attachment  in  the  dorsal  concavity.  At  the 
same  time  the  patient  is  directed  to  sway  the  pelvis  to  the  right. 
This  usually  requires  assistance  at  first,  for  it  brings  into  action 
certain  deep  back  muscles,  over  which  one  has  ordinarily  but 
little  control.  The  shoulders  must  be  kept  level  and  the  proper 
relation  of  the  head  and  neck  to  the  left  shoulder  must  not  be 
disturbed  in  this  forced  stretch  to  the  left  (Fig.  135). 


LATERAL  CURVATURE  OF  THE  SPINE. 


203 


(e)  Chest  Pressing  with  the  Right  Hand.  The  patient 
holding  the  left  arm  in  the  first  position  presses  the  right  hand 
firmly  against  the  dorsal  convexity.     This  posture  may  be  em- 


FlG.  133. 


Typical  lateral  curvature.    Right  dorsal.    Left  lumbar. 


204 


ORTHOPEDIC  SURGERY. 


ployed  to  advantage  if  there  is  a  long  right  dorsal  curve,  when  it  is 
an  efficient  aid  to  the  left-sided  pull  of  the  two  former  exercises. 
(/)  Right  JSIeck  Firm.     The  right  hand  is  placed  behind  the 
neck,  without,  however,  disturbing  the  improved  position  induced 
by  the  first  exercises.     With  both  hands  placed  behind  the  head, 


Fig.  134. 


Lett  iieek  tirm. 


the  arms  being  in  a  symmetrical  position,  there  is  better  mechani- 
cal fixation  of  the  head,  neck,  and  upper  part  of  the  trunk  during 
the  next  exercise  (Fig.  136). 

{g)  Left    Hip   Twistixg  Back"\vaed.     In  posture  {d)  the 
pelvis  was  swayed  slightly  to  the  right ;  it  is  now  twisted  slightly 


LATERAL  CURVATURE  OF  THE  SPINE. 


205 


backward  on  the  left  side  to  overcome  the  twist  in  the  lumbar 
spine  which  usually  throws  this  side  of  the  pelvis  somewhat  for- 
ward. This  correcting  motion  should  be  carried  out  in  the  lower 
dorsal  and  lumbar  segments,  and  it  should  not  affect  the  attitude 
of  the  remainder  of  the  trunk. 


Fig.  135. 


Body  inclination  to  the  left. 


{li)  Left  Oblique  Stride  Standing.  The  pelvic  twist  and 
right-sided  sway  being  rigidly  maintained,  the  left  foot  is  placed 
about  two  foot-lengths  forward  and  a  little  outward.  Upon  this 
leg  the  greater  part  of  the  weight  of  the  body  is  now  supported. 
This  allows  a  slight  downward  tilt  of  the  pelvis  to  the  riglit,  aud 
lessens  the  left  lumbar  couvexity   (Fig.    lo7).     The  positions, 


206 


ORTHOPEDIC  SURGERY. 


attained  by  the  progressive  exercises  to  this  point,  being  main- 
tained, the  patient  continues  with 

{i)  Trunk  Bending  Forward.  In  this  posture,  motion  takes 
place  in  the  hip-joints  only,  as  in  the  first  exercise.  This  exer- 
cise further  emphasizes  the  symmetrical  position  of  the  head  and 
neck,  the  left-sided  inclination  of  the  upper  half  of  the  trunk, 
the  right-sided  inclination  of  the  lower  half,  the  twist  and  down- 

FlG.  136. 


Right  neck  firm. 


ward  tilt  of  the  pelvis  (Fig.  138).  The  return  to  the  improved 
standing  position  should  be  made  in  this  order :  (1)  trunk  raising  ; 
(2)  replacement  of  the  left  foot ;  (3)  return  of  both  arms  to  the 
sides.  This  is  done  slowly  and  carefully  by  the  patient,  who 
attempts  to  maintain  the  improved  posture. 

The  postures  constitute  a  progression  which  cannot  be  learned 
in  less  than  seven  treatments  ;  often  much  more  time  is  required. 


LATERAL  CURVATURE  OF  THE  SPINE. 


207 


As  each  part  is  learned  it  should  be  practised  at  home  until  the 
next  treatment,  when  a  new  posture  is  added,  if  it  appears  that 
progress  can  be  made. 

Fig.  137. 


Left  oblique  stride  standing. 


208  OR  THOPEDIC  SUB  GEE  ¥. 

These  successive  postures  are  in  reality  exercises  in  that  it 
requires  constant  muscular  effort  to  retain  them,  but  they  are  not 
exercises  in  the  sense  of  repeated  alternations  of  position.  The 
series  is  simply  an  elaboration   of  what   is   called   the  keynote 

Fig.  138. 


Trunk  bending  forward. 


posture.  The  raising  of  the  left  elbow,  for  example,  makes  it 
easier  for  the  patient  to  overcome  the  distortion  of  the  upper  part 
of  the  spine  ;  it  also  instructs  him  in  the  manner  of  holding  the 
spine  in  the  improved  position  after  the  arm  is  placed  by  the  side. 


LATERAL  CURVATURE  OF  THE  SPINE.  200 

The  same  is  true  of  all  the  postures  ;  each  one  suggests  and  makes 
correction  easier,  and  after  sufficient  practice  the  patient  should 
be  able  to  assume  the  corrected  position  without  j^lacing  the  arm 
or  the  leg  in  the  preliminary  attitude.  Thus  the  successive 
postures  are,  as  it  were,  letters,  which,  placed  together  one  by 
one,  make  a  complete  word,  or  the  best  possible  position  that  the 
patient  can  assume.  At  first  the  patient  must  use  the  letters  and 
slowly  spell  out  the  corrected  attitude,  but  after  the  muscles  have 
been  educated  by  the  repeated  assumption  of  each  posture,  and 
when  the  perception  of  symmetry  has  been  acquired,  the  corrected 
attitude  may  be  assumed  at  will.  Finally,  the  improved  posture 
will  be  instinctively  retained,  and  will  become  habitual. 

Muscle  Building  Exercises.  In  the  treatment  of  lateral  curvature 
one  aims  to  strengthen  : 

1.  The  posterior  cervical  muscles. 
I  2.   The  dorsal  and  lumbar  muscles. 

'  3.  The  muscles  of  vertebroscapular  attachment.  " . 

4.   The  abdominal  muscles.  "^  ' 

j  5.   The  thigh  and  leg  muscles.  ._ "  ' 

I  6.   The  chest-expanding  muscles. 

The  following  exercises  have  been  selected  as  best  adapted  for 
this  purpose.  Each  one  should  be  performed  five  or  more  times 
according  to  the  strength  of  the  patient. 

(a)  Opposite  Standing,  Head  Bending  Backward,  Re- 
sisted. The  patient  stands  before  a  wall  or  a  shoulder-high  hori- 
zontal bar,  on  which  the  hands  are  placed  with  the  arms  extended. 
The  head  is  bent  forward,  and  is  then  forced  backward,  the  latter 
movement  being  resisted  by  the  hand  of  the  surgeon.  This 
exercise  is  designed  to  strengthen  the  posterior  cervical  muscles. 

(6)  Opposite  Bend  Standing,  Trunk  Eaising,  Resisted, 
The  patient  stands  with  the  upper  part  of  the  thighs  in  contact 
with  a  table  or  horizontal  bar.  The  hands  are  placed  behind  the 
neck  and  the  body  is  bent  forward  on  the  hip-joints  as  in  the 
first  exercise.  The  surgeon,  standing  behind,  places  his  right 
hand  over  the  posterior  dorsal  prominence  and  his  left  over  the 
lumbar  projection.  The  patient  then  raises  the  trunk  to  the  erect 
position  against  the  combined  resistance  (Fig.  139).  With  a 
little  practice  the  surgeon  learns  to  give  an  outward  twisting 
motion  to  his  hands  while  resisting,  which  tends  to  untwist  the 
spinal  rotations.  When  the  dorsal  rotation  to  the  right  is  marked 
this  untwisting  may  be  facilitated  by  encircling  the  patient's  chest 
with  the  left  hand,  while  with  the  right  strong  forward  and  out- 

14 


210 


OB THOPEDIC  SUBGER  Y. 


ward  pressure  is  made  as  the  patient  raises  the  body.  This  exer- 
cise is  for  the  purpose  of  developing  the  muscles  of  the  erector 
spinse  group. 


Fig.  139. 


"Opposite  beud  stauding,"  trunk  raising,  resisted. 


(c)  Prone  Lying,  Head  and  Shoulder  Raising  "the 
Seal."  The  patient  lies  upon  a  table  or  upon  the  floor,  and 
raises  the  head  and  chest — "  looks  at  the  ceiling."  Progression 
is  made  in  the  increased  leverage  of  arm-weight  transference. 


LATERAL  CURVATURE  OF  THE  SPINE. 


211 


212  ORTHOPEDIC  SURGERY. 

1.  With  the  hands  on  the  backs  of  the  thighs. 

2.  With  the  left  hand  behind  the  neck  and  the  right  hand  on 
the  back  of  the  thigh. 

3.  With  both  hands  behind  the  neck,  and  with  the  elbows 
well  out  and  back. 

4.  "  Swimming."  The  arm  motions  of  swimming,  in  three 
counts.  This  exercise  is  to  strengthen  the  muscles  of  the  back 
from  the  head  to  the  pelvis. 

{d)  Prone  Lying,  '' Diving."  The  patient  lies  upon  a 
table,  the  trunk  and  pelvis  projecting  beyond  its  edge,  the  limbs 
being  fixed  by  a  strap  or  by  the  weight  of  another  person.  The 
body  is  then  bent  downward  and  is  raised  again  to  the  horizontal 
position  (Fig.  140).  In  this  exercise  assistance  will  be  required 
at  first.  Progression  is  made  by  transference  of  arm  weights,  as 
in  the  former  exercise,  thus  : 

1.  With  the  hands  on  the  hips. 

2.  With  the  arms  stretched  out  at  right  angles  to  the  body. 

3.  With  the  hands  behind  the  neck. 

4.  With  the  arms  extended  in  the  line  of  the  body. 

This  exercise  is  for  the  purpose  of  strengthening  all  the  mus- 
cles of  the  back. 

(e)  Prone  Lying,  Leg  Raising.  The  patient,  lying  in  the 
prone  posture  upon  the  floor  or  table,  lifts  the  limbs  (overextends) 
alternately,  the  raised  leg  held  perfectly  straight.  When  the  left 
thigh  is  extended,  as  much  as  the  iliofemoral  ligament  will  allow, 
the  left  side  of  the  pelvis  is  tilted  upward  also,  thus  untwisting 
the  lumbar  spine.     Progression  in  this  exercise  is  made  as  follows  : 

1.  Alternate  leg  raising,  unresisted. 

2.  Alternate  leg  raising,  resisted. 

3.  The  leg  motions  of  swimming,  in  three  counts. 

In  this  exercise  the  entire  lower  extremities  must  project 
beyond  the  supporting  table.  The  exercises  are  for  the  purpose  of 
strengthening  the  lumbar  muscles  and  the  extensors  of  the  thigh. 

(/)  Opposite  Sitting,  Backward  Bending  of  the  Trunk. 
The  patient  is  seated  upon  a  bench,  and  the  feet  are  fastened  to 
the  floor.  The  trunk  being  held  in  a  position  of  complete  exten- 
sion, is  bent  slowly  backward,  motion  being  at  the  hip-joint  only. 
Progression. 

1.  With  the  hands  behind  the  hips. 

2.  With  the  left  hand  behind  the  neck,'the  right  hand  on  the  hip. 

3.  With  both  hands  behind  the  neck. 

4.  With  both  arms  extended  upward. 


L A TERA L  CURVATURE  OF  THE  SPINE.  213 

At  first  the  body  is  bent  backward  about  forty-five  degrees, 
later  until  the  head  touches  the  floor.  This  exercise  is  to 
strengthen  the  abdominal  muscles. 

{g)  The  Horizontal  Bar.  "Pull-ups."  The  patient 
hangs  by  the  hands  and  is  assisted  to  "  chin  the  bar."  The  body 
is  then  allowed  to  sink  slowly  back  into  the  former  position,  the 
elbows  are  held  well  back,  and  the  patient  is  instructed  to  bear 
as  much  of  the  weight  as  is  possible  with  the  left  arm  and 
shoulder.  This  exercise  corrects  the  dorsal  curve  by  means  of 
muscular  activity,  and  the  lumbar  curve  by  the  weight  of  the 
suspended  pelvis  and  limbs.  The  muscles  used  are  those  with 
vertebroscapula  attachment. 

Qi)  Left  Leg  Standing,  Pelvis  Tilting.  The  patient 
stands  upon  the  edge  of  a  bench,  supporting  the  weight  on  the 
left  leg,  the  right  leg  being  suspended  beyond  the  side  of  the 
bench.  While  the  head  and  trunk  are  kept  in  the  corrected 
position,  the  pelvis  is  made  to  tilt  sharply  downward  on  the  right, 
by  lowering  the  right  leg,  while  the  left  is  kept  perfectly  stiff. 
This  has  the  effect  of  straightening  the  lumbar  curve. 

{%)  Left  Leg  "Hopping."  Both  hands  are  placed  behind 
the  neck  and  the  weight  is  supported  entirely  upon  the  ball  of 
the  left  foot.  In  this  attitude  the  jjatient  hops  ten  or  more  times. 
This  exercise,  like  the  last,  tends  to  straighten  the  spine  and  to 
strengthen  the  muscles  of  the  left  leg,  which  are  often  somewhat 
weakened  from  disuse. 

{j)  Kespiratory,  Half  Reclining,  Arm  Extensions  and 
Flexions,  Resisted.  The  patient  sits  in  a  chair  with  an  inclined 
back,  or  lies  upon  a  low  table  with  hard  pillows  under  the  mid- 
dorsal  region,  so  that  the  upper  dorsal  and  cervical  segments  of 
the  spine  must  be  overextended.  The  arms  are  stretched  upward 
and  backward,  and  the  hands  are  grasped  by  the  surgeon,  who 
stands  behind  and  resists  the  patient's  downward  pull.  With  the 
upward  stretch  of  the  arms  and  pull  by  the  surgeon  the  patient 
inhales  forcibly.  W^ith  the  downward  pull  against  resistance, 
the  patient  exhales  forcibly.  This  exercise  is  made  in  the  rhythm 
of  slow  breathing. 

When  the  patient  has  been  thoroughly  instructed  'in  self- 
correction  and  in  the  exercises  for  muscle  building,  general 
gymnastics  for  systematic  motor  training  may  be  given  effectively 
to  groups  of  fifteen  or  twenty  pupils. 

The  exercises  illustrated  on  pages  187-195  will  serve  this 
pur])ose  satisfactorily. 


214  ORTHOPEDIC  SURGERY. 

These  two  systems  of  treatment  by  gymnastics  have  been 
selected  as  the  most  practicable  of  the  many  that  have  been 
devised.  It  may  be  stated  that  any  treatment  that  makes  the 
spine  more  flexible,  that  overcomes  faulty  attitudes,  and  that 
strengthens  the  muscles,  must  be  of  benefit  to  the  patient,  the 
degree  of  benefit  corresponding  to  the  persistence  and  energy  of 
the  pupil  and  the  instructor  rather  than  to  any  particular  theory 
on  which  such  treatment  is  based.  The  rotation  of  the  vertebral 
bodies  is  increased  by  forward  bending  of  the  trunk,  and,  as  this 
is  the  more  important  element  of  lateral  curvature,  it  is  evident 
that  extension  or  overextension  of  the  spine,  combined  with  lateral 
twisting  in  such  a  manner  as  to  reverse  the  habitual  inclination, 
will  most  directly  lessen  or  correct  the  distortion.  If  improvised 
exercises  are  conducted  from  this  standpoint  they  will  always  be 
effective. 

The  Removal  of  Superincumbent  Weight,  The  removal  of  super- 
incumbent weight  by  the  assumption  of  the  reclining  posture 
whenever  the  patient  is  fatigued  is  an  important  adjunct  in  the 
treatment  of  a  certain  class  of  cases.  The  patient  should  lie, 
preferably,  upon  a  hard  support  in  the  supine  posture,  with  the 
arms  extended  above  the  head.  If  the  dorsal  kyphosis  is  exag- 
gerated, a  firm  cushion  between  the  shoulders  or  under  the 
projecting  ribs  will  aid  to  expansion  of  the  chest  and  favor  the 
correction  of  the  deformity. 

Self-suspension.  Self-suspension,  by  means  of  the  halter 
and  pulley,  is  of  service  in  overcoming  secondary  contractions  of 
the  tissues,  and  thus  it  aids  in  the  correction  of  deformity.  It 
is  often  efficacious,  also,  in  relieving  the  discomfort  that  is  some- 
times a  troublesome  symptom  when  the  distortion  is  extreme. 
While  the  patient  is  suspended  forcible  manual  correction  of  the 
deformity  can  be  applied  to  advantage. 

Suspension  from  the  horizontal  bar  acts  in  a  similar  manner, 
although  it. is  less  effective  than  when  the  traction  is  made  upon 
the  entire  spine.  In  this  form  of  suspension  the  bar  should  be 
oblique  in  direction,  the  high  side  for  the  low  shoulder.  Thus, 
a  passive  "  keynote  "  is  induced  while  the  patient  is  suspended. 
Exercises  in  this  position,  for  example,  flexion,  extension,  and 
abduction  of  the  thighs,  swaying  the  trunk  from  side  to  side, 
"  chinning  "  the  bar,  and  the  like,  are  useful. 

The  Use  of  Braces  or  Other  Supports.  In  the  treatment  of  the 
ordinary  type  of  lateral  curvature,  when  there  is  an  opportunity 
for  proper  gymnastic    training,   direct    support    is  not  usually 


LATERAL  CURVATURE  OF  THE  SPI^E. 


215 


indicated.  There  are,  however,  cases  even  in  this  class  in  which 
the  deformity  habit  is  so  persistent,  and  in  which  the  vokintary 
efforts  of  the  patient  to  assume  a  better  attitude  are  so  ineffective, 
that  support  may  be  employed  for  a  time  with  advantage. 


Fig.  141. 


Fig.  142. 


Self-suspension,  illustrating  the  eflfect  of  traction  in  lessening  deformity  induced  by 
paralysis.    (Gibney.)    In  such  cases  support  is  essential. 


The  best  support  is  a  plaster  corset  applied  with  as  much  manual 
corrective  force  as  is  practicable  while  the  patient  is  suspended  in 
the  upright  posture  if  lateral  deviation  is  most  marked  or  if  the 


216  ORTHOPEDIC  S  UB GER  Y. 

curvature  is  flexible ;  in  the  horizontal  preferably  if  the  rotation 
is  the  prominent  feature  of  the  deformity. 

If  correction  is  attempted  in  the  horizontal  attitude  the  patient 
may  be  suspended  in  the  prone  posture  on  a  strip  of  cotton  cloth 
(the  hammock  method).  As  this  sinks  under  the  weight  of  the 
trunk,  it  falls  into  the  attitude  of  overextension,  which  is  that 
most  favorable  for  the  untwisting  of  the  rotated  spine.  When 
the  deformity  is  marked,  the  body  may  be  suspended  in  the 
lateral  attitude  by  means  of  a  sling  of  cotton  cloth  passed  about 
the  prominent  ribs ;  thus  the  weight  of  the  body  acts  as  a  cor- 
recting force  during  the  application  of  the  corset. 

In  using  such  corrective  force  one  endeavors,  if  possible,  to 
overcorrect  the  habitual  deformity  and  the  less  marked  chang-es  in 
the  anteroposterior  contour  as  Avell.  For  example,  if  the  lumbar 
region  is  flat  one  attempts  to  reproduce  the  normal  lordosis,  and 
if  the  body  is  habitually  inclined  in  one  direction  one  endeavors 
to  sway  it  to  the  opposite  side,  and  to  efface  the  so-called  high  hip. 

This  attitude  of  overcorrection  assured  by  the  corset,  combined 
with  exercises,  is  especially  efficacious  from  the  curative  stand- 
point in  the  treatment  of  single  flexible  curves.  If  the  second  or 
compensatory  curvature  has  already  appeared,  one  attempts  to 
overcorrect  the  primary  deformity  and  directs  exercises  for  the 
purpose  of  straightening  the  second  curve  while  the  patient  is 
wearing  the  corrective  corset.  For  as  the  compensatory  curva- 
ture is  usually  m  the  dorsal  region,  it  may  be  considerably  influ- 
enced by  postures  of  the  arms  and  shoulders.  As  often  as  pos- 
sible during  the  day  the  patient  should  endeavor  to  improve  upon 
the  attitude  which  the  corset  enforces,  by  assuming  the  keynote 
position  and  by  flexing  and  extending  the  trunk  on  the  hips. 
For  general  exercises  the  corset  may  be  removed,  and,  as  a  rule, 
it  need  not  be  worn  at  night,  although  in  the  treatment  of  young 
subjects  its  constant  use  for  one  or  more  weeks  is  of  service  in 
enforcing  a  proper  attitude. 

When  the  deformity  is  dependent  upon  irremediable  injury  or 
disease,  such,  for  example,  as  anterior  poliomyelitis  or  empyema, 
some  form  of  brace  must  be  employed  constantly  to  prevent  exces- 
sive lateral  deviation  of  the  trunk  ;  and  in  cases  of  fixed  deformity 
in  older  subjects,  especially  if  the  patient's  occupation  is  fatiguing, 
a  support  may  be  indicated  to  relieve  symptoms  of  discomfort  or 
pain. 

Support  is  employed  primarily  with  the  aim  of  preventing  an 
increase  of  deformity  and  to  relieve  symptoms  incidental  to  the 


LATERAL  CURVATURE  OF  THE  SPINE. 


217 


deformity.  It  may  serve,  also,  in  some  degree  as  a  corrective 
appliance.  If  it  holds  the  spine  in  the  extended  position  or 
induces  lordosis,  it  may,  by  relieving  the  anterior  portion  of  the 
column  in  part  from  the  deforming  influence  of  superincumbent 
weight,  induce  or  permit  a  slight  lessening  of  the  rotation  of  the 
vertebral  bodies.  On  this  principle  a  light  steel  brace  after  the 
Taylor  model  may  be  as  effective  as  any  of  the  more  complicated 
appliances,  as  was  suggested  many  years  ago  by  Judson.  Corsets 
of  other  material  than  plaster,  for  example,  of  paper,  or  of  alumi- 
num, as  suggested  by  Phelps,  may  be  employed  when  the 
deformity  is  fixed  and  when  no  change  in  the  position  or  size  of 


The  Knight  spinal  brace,  as  used  in  lateral  curvature.  A  leather  or  canvas  band,  made 
adjustable  by  lacings,  is  stretched  from  the  posterior  upright  to  the  side  bar  on  the  side  of 
the  dorsal  convexity. 

the  trunk  is  to  be  expected.  The  Knight  brace,  when  carefully 
adjusted,  appears  to  meet  the  requirements  fairly  well,  and  when 
less  support  is  needed  an  ordinary  corset  strengthened  by  light 
steels  may  be  sufficient. 

Forcible  Correction  of  Deformity.  In  the  treatment  by  gymnas- 
tic exercises  the  patients  are  supposed  to  overcome  by  voluntary 
effort,  as  far  as  is  possible,  the  secondary  accommodative  contrac- 
tions of  the  soft  parts  that  prevent  the  correction  of  the  deformity, 
the  heavy  work  of  the  Teschuer  system  being  particularly  effec- 
tive for  this  purpose.  But  in  many  instances  the  voluntary  cor- 
rection of  deformity  may  be  supplemented  with  advantage  by  the 


218 


ORTHOPEDIC  SURGERY. 


Fig.  144. 


employment  of  force.  For  example,  the  patient  may  use  the 
weight  of  the  body  as  a  means  of  correction  by  forcibly  flexing 
the  trunk  over  a  padded  bar  (Fig.  149)  and  a  variety  of  similar 
postures,  either  active  or  passive,  with  or  without  suspension, 
may  be  utilized  with  the  same  object.  Corrective  force  applied 
by  the  hands,  the  patient's  trunk  being  flexed  and  rotated  in  the 

directions  opposed  to  the  de- 
formities, although  the  most 
effective  method,  is  the  most 
fatiguing,  and  machines  have 
been  constructed  with  the  aim 
of  applying  the  force  in  a  simi- 
lar manner.  This  is  illustrated 
by  the  appliance  of  Hoffa, 
which  has  been  modified  by 
Schede  and  others.  In  this  ma- 
chine the  patient  is  suspended, 
the  hips  are  fixed,  and  the  press- 
ure screws  are  applied  upon 
the  convexities  of  the  double 
curve,  with  the  aim  of  untwist- 
ing the  spine.  The  correction 
is  maintained  for  fifteen  min- 
utes or  longer,  and  it  is  then 
followed  by  the  regular  exer- 
cises of  the  day  (Fig.  144). 

The  Forcible  Correction  of  De- 
formity Combined  with  Fixation. 
Forcible  correction  and  fixa- 
tion is  the  treatment  of  selec- 
tion for  resistant  lateral  curva- 
ture in  early  childhood,  because 
one  cannot  command  the  co- 
operation of  the  patient  in 
maintaining  the  proper  attitude, 
and  because  the  rapid  growth  at  this  age,  which  favors  the  in- 
crease of  the  deformity,  is  equally  favorable  to  its  cure  if  the 
static  conditions  can  be  changed. 

For  example,  one  treats  the  severe  rhachitic  kyphosis  of  infancy 
by  fixation  on  the  stretcher  frame  in  the  attitude  of  overexten- 
sion, and  by  daily  manual  correction  of  the  deformity.  And  in 
the   treatment  of  older   children,  in  whom  posterior  or  lateral 


Forcible  correction  by  means  of  the  modi- 
fied Hoffa  appliance.  (Bradford  and  Brack- 
ets) 


LATERAL  CURVATURE  OF  THE  SriNE.  219 

deformity  is  fixed,  one  is  justified  in  using  the  same  method  for 
its  relief  and  cure  that  would  be  employed  in  the  treatment  of 
Pott's  disease.  In  this  class  the  plaster-of-Paris  jacket,  applied 
while  the  trunk  is  held  in  the  best  possible  position,  is  the  treat- 
ment of  selection — a  treatment  that  should  be  continued  until  the 
deformity  is  cured  or  until  further  rectification  by  this  means  is 
found  to  be  impossible. 

The  most  convenient  method  of  applying  the  jacket  is  by  means 
of  the  ordinary  suspension  apparatus.  The  back  having  been 
carefully  padded  at  the  points  of  pressure,  the  patient  is  sus- 
pended,  and  while    traction  and    manual    corrective  force  are 

Fig.  145. 


Congenital  scoliosis.    After  treatment  for  three  years  by  forcible  correction  and  fixation 
by  plaster  jackets,    Stiowing  the  disappearance  of  the  rotation. 

exerted  the  plaster  bandages  are  applied.  In  this  correction  two 
points  are  of  especial  importance :  to  attain  as  much  extension  or 
overcorrection  as  possible,  and  to  sway  the  entire  body  in  the 
direction  opposite  to  the  habitual  inclination.  By  overextension 
one  removes  the  weight  in  part  from  the  vertebral  bodies  that 
are  primarily  deformed,  and  by  lateral  correction  one  endeavors 
to  change  the  relation  of  the  weight  to  the  distorted  part.  This 
improved  position  must  be  carefully  maintained  by  the  hands 
until  the  plaster  bandages  have  become  firm.  The  jackets  may 
be  changed  at  intervals  of  about  a  month,  and  at  each  applica- 
tion one  attempts  to  improve  upon  the  former  position. 

Lovett'  has  urged  the  importance  of  correcting  anteroposterior 

I  Tram-actions  American  Orthopedic  Association,  1901,  vol.  xiv. 


220  ORTHOPEDIC  SUPMEBY. 

deformities  by  straightening  the  compensatory  curves.  For 
example,  if  a  dorsal  convexity  is  accompanied  by  a  lumbar  con- 
cavity the  jacket  should  be  applied  while  the  lumbar  segment  is 
straight.  This  may  be  accomplished  by  supporting  the  trunk  in 
the  prone  posture  on  a  hammock,  the  legs  hanging  downward  on 
either  side,  or  in  the  sitting  posture.  The  effect  of  flexion  of 
the  thighs  in  straightening  the  lumbar  spine  is  illustrated  in 
Fig.  145.  Theoretically,  if  this  attitude  persists,  it  should 
induce  a  flattening  of  the  abnormal  kyphosis  of  which  the  lor- 
dosis is  the  effect,  particularly  if  the  improved  position  is  favored 
by  appropriate  postures  and  exercises. 

In  the  cases  in  which  corrective  force  is  employed  the  jacket 
is  used  in  preference  to  the  corset,  because  it  holds  the  spine 
more  perfectly.  It  is,  of  course,  a  disadvantage  to  employ 
such  restraint,  but,  as  has  been  stated,  the  prognosis  in  fixed 
rotary  lateral  curvature  in  a  young  child  is,  as  regards  ultimate 
deformity,  extremely  unfavorable,  and  one  is  justified,  there- 
fore, in  sacrificing  muscular  activity  in  order  that  the  original 
deformity  of  the  bones  may  be  remedied.  As  an  illustration  of 
persistence  in  this  method  of  treatment,  it  may  be  stated  that  it 
was  continued  by  me  for  nearly  five  years  in  one  case  of  extreme 
scoliosis  of  congenital  origin  with  most  gratifying  success  (Fig. 
145). 

The  jackets  may  be  applied,  also,  in  the  horizontal  position, 
traction  being  exerted  upon  the  arms  and  legs,  combined  with 
manual  pressure  on  the  trunk,  somewhat  after  the  manner  of  the 
Calot  method  of  correction  of  the  deformity  of  Pott's  disease. 
Or  the  body  may  be  supported  by  a  sling  or  other  appliance.  In 
certain  instances  one  is  able  to  correct  the  deformity  more  effect- 
ually by  horizontal  than  by  vertical  suspension  in  the  manner 
already  described. 

When  the  deformity  has  been  overcome,  or  when  the  contin- 
uation of  the  treatment  seems  undesirable,  the  jacket  may  be 
replaced  by  a  corset,  which  may  be  removed  for  daily  massage  and 
for  exercises.  This  may  be  finally  discarded  when  the  muscular 
strength  has  been  regained. 

As  has  been  stated,  forcible  correction  and  fixation  is  essen- 
tially a  treatment  of  deformity  in  early  childhood.  But  in  cer- 
tain instances,  when,  for  example,  the  deformity  is  extreme  or  is 
increasing  rapidly,  it  may  be  employed  in  adolescence.  In  the 
treatment  of  this  class  of  cases  the  plaster  jacket  is  usually 
applied  while  the  patient  is  fixed  in  the  best  possible  position  by 


LATERAL  CURVATURE  OF  TLIE  SPINE.  221 

means  of  some  form  of  pressure  apparatus,  as  is  illustrated  in 
Fig.  144. 

Forcible  correction  of  deformity  in  this  manner,  under  anes- 
thesia, Avith  subsequent  fixation  of  the  trunk  and  of  the  head,  if 
possible,  in  the  overcorrected  position,  is  advocated  by  Wullstein,^ 
and  it  may  be  of  service  in  certain  cases. 

The  Volkmann  Seat.  In  cases  of  primary  lumbar  curva- 
ture, or  when  the  secondary  curve  of  this  region  is  pronounced, 
the  attitude  may  be  improved  and  the  deformity  may  be  cor- 
rected in  part  by  seating  the  patient  on  an  inclined  plane,  the 
high  side  beneath  the  low  hip,  thus  lessening  the  convexity  of 
the  curve. 

The  High  Shoe.  The  same  object  may  be  attained  in  the 
erect  posture  by  the  use  of  a  higher  heel,  or  heel  and  sole.  The 
elevation  may  be  from  a  half-inch  to  an  inch  and  a  quarter,  the 
amount  being  regulated  by  its  effect  upon  the  contour  of  the 
trunk. 

Posture  and  Support  during  Recumbency.  The  atti- 
tudes habitually  assumed  during  recumbency  should  be  investi- 
gated. The  bed  should  be  provided  with  a  hard  mattress  and  a 
low  pillow,  and  the  patient  should  be  encouraged  to  lie  habitually 
upon  the  side  which  opposes  the  deformity,  or  upon  the  back. 
The  rectification  induced  by  such  an  attitude  may  be  still  further 
increased  by  the  use  of  a  hard  pillow  beneath  the  convexity  or 
beneath  the  back,  and  in  certain  instances  the  Barwell  sling  may 
be  employed  with  advantage. 

General  Treatment.  The  importance  of  improving  the  gen- 
eral condition  of  the  patient  by  regulation  of  the  diet,  by  cold 
baths,  and  by  active  exercise  in  the  open  air  is  self-evident.  The 
strain  upon  the  back  should  be  lessened  by  providing  proper 
seats  and  by  limiting  the  time  passed  in  passive  attitudes,  and  by 
lessening,  as  far  as  possible,  the  restraint  of  the  clothing.  These 
precautions  are  of  almost  equal  importance  with  the  active  treat- 
ment. 

The  Duration  of  Treatment.  The  duration  of  treatment  depends, 
of  course,  upon  the  character  of  the  deformity  and  upon  its  causes. 
In  the  ordinary  type  of  adolescent  scoliosis  the  duration  of  active 
treatment  is  usually  from  three  to  six  months.  In  this  time  the 
muscles  may  be  so  strengthened  and  the  necessity  for  constant 
attention  to  the  attitudes  may  be  so  impressed  upon  the  patient 
that  the  simple  exercises  which  may  be  performed  at  home  may 

'  Zeit.    .  Orlhop.  Chir.,  1902,  Bd.  x.  H.  2. 


222        '  ORTHOPEDIC  SURGERY. 

be  sufficient.  In  such  exercises  the  most  important  postures  are 
those  which  hyperextend  the  spine.  The  constant  effort  should 
be  to  make  motion  in  one  direction  as  free  as  in  another,  and  to 
practice  postures  that  tend  to  reduce  deformity.  In  all  cases  it 
is  well,  if  possible,  to  keep  the  patient  under  supervision  during 
the  period  of  growth. 


CHAPTER   IV. 

DEFORMITIES  OF  THE  SPINE  (Continued).     DEFORMITIES  OF 

THE  CHEST.    THE  FUNCTIONAL   PATHOGENESIS 

OF  DEFORMITY. 

Variations  in  the  Contour  of   the  Spine. 

One  recognizes  a  certain  contour  of  the  spine  as  normal,  but 
there  are  variations  from  this  type  which,  within  certain  limits, 
can  hardly  be  classed  as   abnormal.     Two  of  these  have  been 


Fig.  146. 


Fig.  147. 


The  hollow  round  back.    (Hofifa.j 


The  round  back.    (Hoffa.) 


mentioned:  the  round  back  (Fig.  147)  in  which  there  is  a  gen- 
eral forward  droop  most  marked  at  the  shoulders,  and  the  hollow 


224  ORTHOPEDIC  SURGERY. 

round  back  (Fig.  146)  in  which  the  dorsal  kyphosis  and  the 
lumbar  lordosis  are  somewhat  exaggerated.  A  third  type  is  the 
flat  bach  (Fig.  82)  in  which  there  is  neither  a  lumbar  lordosis  nor 
a  dorsal  kyphosis.  In  the  marked  cases  there  is  an  actual  promi- 
nence in  the  lumbar  region,  while  the  scapulae  project  backward, 
overhanging  the  flattened  dorsal  spine.  This  type  of  back  is  the 
result,  in  many  instances,  of  a  rhachitic  kyphosis  which  was  most 
prominent  in  the  lumbar  region,  and  it  often  follows  a  primary 
lateral  rotation  of  the  lumbar  vertebrse.  The  flat  back  and  the 
round  back  predispose  to  lateral  curvature.  Deviations  from 
the  normal  contour  of  the  spine  are  attended  by  a  change  in  the 
inclination  of  the  pelvis  and  in  the  relation  of  the  support  of  the 
limbs  and  trunk.  The  round  back  (Fig.  147)  is  almost  always 
indicative  of  weakness,  and  it  is  often  accompanied  by  other 
postural  deformity,  especially  often  by  weak  feet. 

Anteroposterior  Deformities  of  the  Spine. 

Kyphosis.  As  has  been  stated  in  the  chapter  on  Pott's  dis- 
ease, the  spine  is  practically  straight  at  birth.  If  during  the 
early  weeks  of  life  an  infant  be  placed  in  the  sitting  posture  the 
head  falls  forward  and  the  spine  bends  into  a  long  posterior  curve, 
the  posture  of  weakness.  The  normal  anterior  convexity  of  the 
cervical  section  is  established  when  the  gain  in  muscular  power 
enables  the  infant  to  hold  the  head  erect,  and  that  of  the  lumbar 
region  when  the  pelvis  is  tilted  downward  by  the  extension  of 
the  thighs  in  the  erect  posture. 

In  the  erect  posture  the  constant  tendency  of  the  weight  of  the 
head  and  of  the  thoracic  and  abdominal  organs  is  to  draw  the 
spine  forward  and  to  re-establish  the  original  posterior  curve. 
This  tendency  is  resisted  by  the  action  of  the  posterior  muscles 
of  the  trunk.  Whenever,  therefore,  the  muscular  power  is 
lessened  or  the  body  is  overburdened,  or  whenever  the  spine  is 
weakened  by  disease,  the  tendency  toward  the  original  curve  of 
weakness  becomes  apparent  (Fig.  148).  Thus,  the  causes  of  an 
abnormal  increase  in  the  posterior  curvature  of  the  spine  are  very 
numerous.  It  is,  as  has  been  stated,  the  characteristic  attitude 
of  weakness,  as  is  illustrated  in  infancy  and  in  old  age.  It  is 
one  of  the  common  occupation  deformities  of  adult  life ;  it  is  a 
common  postural  deformity  of  childhood  and  adolescence.  It 
may  be  induced  by  a  variety  of  diseases  that  lessen  the  resistance 
of   the   spine  or  that  interfere  with  its  function.      For  example, 


DEFORMITIES  OF  THE  SPINE. 


225 

Pott's 


by  rhachitis,   spondylitis    deformans,   osteitis    deformans 
disease,  and  affections  of  a  similar  nature. 

The  kyphosis  of  rhachitis  is  most  marlced  in  the  lower  region, 
that  of  spondylitis  deformans  may  involve  the  entire  spine,  while 
the  simple  postural  curvature  is  most  marked  in  the  upper  dorsal 
region — "  round  shoulders."  In  a  number  of  the  postural 
deformities  the  increase  in  the  dorsal  kyphosis  is  balanced  by  an 
increased  lordosis,  and  in  this  form  there  is  simply  an  exaggera- 


Marked  posterior  curvature  of  the  spiue  apparently  induced  by  weakness  incidental 

to  illness. 

tion  of  the  normal  curves  of  the  spine — the  "hollow  round" 
back.  In  other  instances  there  is  a  general  forward  droop  of 
the  trunk  in  which  the  lumbar  lordosis  may  be  lessened ;  this 
form  is  more  common  in  childhood — the  "  round  "  back. 

The  forms  of  kyphosis  tliat  are  the  direct  result  of  disease 
have  been  described  elsewhere.  Postural  h/phosls—"  ronml 
shoulders" — is  one  of  the  common  deformities,  and  in  childhood 

15 


226 


ORTHOPEDIC  SURGERY. 


its  etiology  is  similar  to  that  of  lateral  curvature,  of  which  it 
may  be  a  predisposing  cause.  Round  shoulders  and  the  accom- 
panying flat  chest  may  be  induced  also  by  obstructions  in  the 
respiratory  passages,  such  as  enlarged  tonsils,  adenoids,  and  the 
like,  or  by  bronchitis  or  heart  disease.  Another  predisposing 
cause  is  clothing  that  prevents  the  full  expansion  of  the  chest 
and  the  extension  of  the  arms,  and  even  the  weight  of  clothing 
suspended  from  the  shoulders  may  be  a  factor  in  the  etiology. 


Fig.  149. 


Fig.  150. 


Exercises  for  the  correction  of  posterior  curvatures  ot  the  spine.    (Hofta.) 


These  and  other  possible  contributing  causes  should  be  investi- 
gated in  all  cases  of  this  type. 

A  marked  type  of  deformity  is  sometimes  seen  in  adolescents 
(Fig.  75),  induced  apparently  by  posture  and  by  overwork, 
although  in  most  instances  it  may  be  assumed  that  a  slighter 
deformity  of  long  standing  serves  as  a  predisposing  cause.  In 
this  type  the  deformity  is  resistant,  and  there  is,  as  a  rule,  pain 
or  discomfort  most  marked  in  the  lumbar  region. 


DEFORMITIES  OF  THE  SPINE. 


227 


Treatment.  The  treatment  is  similar  to  that  of  lateral  curva- 
ture. The  assumption  of  the  military  attitude  with  the  head 
erect,  the  chin  depressed,  the  shoulders  thrown  back,  the  chest 
expanded,  and  the  abdomen  retracted,  should  be  encouraged. 
And  those  exercises  that  expand  the  chest  and  that  strengthen 
the  muscles  of  the  upper  part  of  the  spine  are  especially  impor- 
tant. (Such  exercies  are  illustrated  by  Figs.  97,  98,  105,  106, 
111,  112,  121,  127,  129,  131,  149,  and  150.)  If  the  range  of 
vertical  extension  of  the  arms  is  limited,  this  restriction  must  be 
overcome  before  the  deformity  of  the  spine  can  be  permanently 

Fig.  151. 


Tempered  steel  uprights  for  round  shoulders.    (Bradford  and  Lovett.) 

improved.  In  well-marked  cases  the  patient  should  be  encour- 
aged to  read  or  study  in  the  prone  posture;  in  this  attitude,  in 
which  the  trunk  must  be  supported  upon  the  elbows  and  the  head 
held  backward,  there  is  necessarily  an  involuntary  correction  of  the 
deformity.  In  certain  instances  a  light  spinal  brace  or  corset  may 
be  employed  during  the  hours  when  the  passive  attitude  must  be 
assumed  (Fig.  151).  Shoulder  braces,  so-called,  are  useless,  because 
the  lumbar  lordosis  is  increased  when  the  shoulders  are  drawn  back- 
ward. Clothing  should  not  restrict  the  movements  of  the  arms 
or  trunk,  and  as  little  weight  as  possible  should  be  suspended 
from   th(!  shoulders.      In  the   more  extreme  cases,  in  which  the 


228  ORTHOPEDIC  SURGERY. 

kyphosis  is  of  long  duration  and  rigid,  forcible  correction  after 
the  Calot  method  is  indicated  as  a  preliminary  treatment.  Fixed 
support,  preferably  the  plaster  corset,  is  employed  until  the 
patient  has  become  accustomed  to  the  new  attitude.  Afterward 
treatment  by  exercise  and  posture  is  continued  as  in  the  ordinary 
type.  Whenever  a  patient  is  under  treatment  for  deformity  of 
the  trunk  the  attempt  should  be  made  to  restore  the  proper  rela- 
tion of  the  body  and  limbs,  and  thus  to  restore  the  general 
symmetry  of  the  body. 

Lordosis.  Lordosis,  or  an  abnormal  hollowness  of  the  back, 
is  far  less  common  than  kyphosis.  It  is  not  a  simple  postural 
deformity,  but  it  is  usually  secondary  to  disease  or  deformity 
either  of  the  spine  or  of  the  adjoining  members.  For  example, 
lordosis  may  be  induced  by  flexion  contraction  of  the  thighs  ;  it 
is  a  symptom  of  congenital  displacement  of  the  hips ;  it  is  some- 
times a  result  of  certain  forms  of  nervous  disease,  in  which, 
because  of  muscular  weakness,  the  body  is  swayed  backward  to 
retain  the  balance,  as  in  pseudohypertrophic  paralysis.  Lordosis 
in  the  lumbar  region  may  be  a  compensation  for  a  kyphosis  in 
the  upper  segment.  It  is  caused  directly  by  spondylolisthesis. 
It  may  be  a  congenital  deformity,  and  it  is  said  to  be  a  peculiarity 
of  contortionists. 

Treatment.  As  lordosis  is  usually  a  secondary  deformity  its 
treatment  would  be  included,  in  the  treatment  of  its  causes.  In 
some  instances  the  discomfort  which  is  usually  present  when  the 
deformity  is  well  marked  may  be  relieved  by  a  proper  corset 
sufficiently  strong  to  support  the  back. 

Congenital   Elevation  of  the  Scapula. 

Synonym.     Sprengel's  deformity. 

Spreugel's  deformity  is  a  congenital  elevation  of  the  scapula 
above  the  level  of  its  fellow,  an  elevation  accompanied  in  most 
instances  by  rotation,  so  that  its  lower  angle  is  brought  nearer  to 
the  spine.  The  cervical  muscles  passing  to  the  scapula  are  short- 
ened and  changed  in  direction.  Thus,  its  mobility  is  lessened 
and  consequently  the  range  of  vertical  extension  of  the  arm  is 
restricted.  In  many  instances  the  deformity  is  accompanied  by 
a  lateral  curvature  of  the  spine,  the  convexity  being  usually 
toward  the  deformed  side.  In  a  case  treated  at  the  Hospital  for 
Ruptured  and  Crippled  the  elevation  of  the  scapula  was  accom- 
panied by  marked  torticollis  and  asymmetry  of  the  face,  and  in 


DEFORMITIES  OF  THE  SPINE. 


229 


Fig   152 


2  cases  reported  by  Wilson  and  Rugh'  the  posterior  border 
of  the  scapula  was  attached  by  a  bony  process  to  the  spine  of 
the  seventh  cervical  vertebra.  In  4  cases — 3  reported  by 
Kolliker^  and  1  by  Hoffa — the  projecting  upper  border  of  the 
scapula,  reaching  nearly  to  the  clavicle,  was  mistaken  for  an 
exostosis. 

The  first  adequate  account  of  the  deformity  was  that  of  Spren- 
gel,^  who  described  4  cases  in  children  from  one  to  seven  years 
of  age.  In  1898  Pitsch*  described  17  other  cases  collected  from 
the  literature,  and  two  years  later  Roger^  reported  32.  Of  these, 
30  were  unilateral  and  2  were  bilateral. 

Etiology.  The  etiology  is  doubtful,  but  the  deformity  appears 
to  be  the  result  of  a  constrained  position  of  the  fcetus  in  utero. 
In  two  of  Sprengel's  cases,  seen  soon 
after  birth,  the  arm  appeared  to  have 
been  fixed  behind  the  back  of  the  child. 

It  is  of  interest  to  note  that,  accord- 
ing to  Chievitz,  the  upper  limb  is  in  its 
origin  a  cervical  appendage  retaining 
an  elevated  position  during  foetal  life, 
and  that  interference  with  its  desceui. 
by  constraint  or  otherwise  may  explain 
the  etiology. 

Congenital  elevation  of  the  scapula 
may  be  simulated  by  the  distortion  and 
muscular  atrophy  resulting  from  birth 
palsy,  or  even  by  certain  cases  of  rotary 
lateral  curvature  in  which  the  scapula 
is  elevated  and  prominent. 

Treatment.  If  the  case  is  seen  in 
childhood  and  if  the  contraction  of  the 
vertebroscapula  muscles  is  extreme,  the 
shortened  tissues  may  be  divided  by  open 
incision  as  in  torticollis,  and  if  the 
scapula  is  joined  to  the  spine,  the  bony  process  should  be  re- 
moved. In  older  subjects  no  treatment  other  than  that  for  the 
lateral  curvature  is,  as  a  rule,  indicated. 


Congenital  elevation  of  the  left 
scapula.    (Wilson  and  Rugh.) 


I  Annals  of  Surgery,  April,  1900. 
'■"■  Archiv  f.  klin.  Chir.,  189],  Bd.  xlii. 
■•  Zeit.  f.  Orlh.  Chir.,  Bd.  vi.  H.  1. 


2  Centralbl.  f.  Chir.,  1895. 


Ibid.,  1902,  Bd.  ix. 


230  OR THOPEDIC  S  UB GER  Y. 

The  Absence  of  Vertebrae. 

Absence  of  vertebrse  is  usually  associated  with  rhachischisis. 
Several  cases,  however,  have  come  under  my  observation  in 
which  there  was  absence  of  vertebrse  without  other  malforma- 
tion. In  two  of  the  cases  the  deficiency  was  in  the  cervical 
region,  in  the  others  in  the  lumbar.  The  noticeable  shortness 
of  the  affected  section  of  the  spine  was  the  only  symptom. 

Deformities  of  the  Chest. 

The  Flat  Chest.  The  so-called  flat  chest  is  an  accompani- 
ment of  the  round  back  (Fig.  147).  In  most  instances  the 
chest  is  not  actually  flattened  in  the  sense  that  its  anteroposte- 
rior diameter  is  diminished.  It  appears  flatter  because  the  shoul- 
ders and  scapulae  are  displaced  forward. 

Woods  Hutchinson  has  called  attention  to  the  fact  that  the 
so-called  flat  chest  is  usually  a  round  chest,  in  the  sense  that  it  is 
actually  deeper  than  the  normal,  a  persistence  of  the  foetal  type. 
He  suggests  that  such  persistence  may  be  one  of  the  causes  of 
so-called  round  shoulders,  the  round  chest  affording  no  adequate 
support  for  the  scapulae. 

Hutchinson'  has  presented  an  index  showing  the  relative  depth 
of  the  chest  at  different  ages,-  illustrating  the  progress  from  the 
keel  chest  of  the  lower  orders  to  the  bellows-shape  of  the  adult 
human  form.  This  index  is  found  by  dividing  the  anteroposterior 
diameter  at  the  nipples  by  the  transverse  diameter  at  the  same 
level ;  hence  the  lower  the  index,  the  longer  and  flatter,  more 
bellows-like  the  chest. 

FcEtal  index 103 

Infantile  index       ...               87 

Child            ■' 90 

Adult           "           72 

Treatment.  The  treatment  of  the  so-called  flat  chest  is  similar 
to  that  of  the  round  shoulders  with  which  it  is  often  combined — 
that  is,  by  exercises  conducted  with  the  special  object  of  improv- 
ing the  strength  of  the  muscles  of  the  back  and  increasing  the 
expansion  of  the  upper  part  of  the  chest.  The  importance  of 
correcting  the  deformity,  which  interferes  with  the  proper  expan- 
sion of  the  lungs  and  thus  predisposes  to  disease,  should  be 
evident. 

1  Journal  Ajuerican  Medical  Association,  September  11,  1897. 


DEFORMITIES  OF  THE  CHEST. 


231 


Pigeon  Chest.     Synonym.     Pectus  carinatum. 

The  pigeon,  or  keel-shaped,  chest  resembles  the  quadrupedal 
type  in  that  the  anteroposterior  is  increased  at  the  expense  of  the 
lateral  diameter.  The  sternum  is  thrust  forward  and  downward 
like  the  keel  of  a  boat,  the  lateral  compression  being  most  marked 
at  the  junction  of  the  ribs  and  the  cartilages.  This  deformity  is 
almost  always   acquired   (Fig.  153);    it  is   usually  an  effect  of 


Fig.  153. 


General  rhachitic  distortions  and  pigeon  chest. 

rhachitis,  and  it  is  described  under  that  heading.  It  may  be 
induced  by  obstruction  of  respiration  caused  by  enlarged  tonsils 
and  the  like,  if  this  is  present  at  an  early  age.  It  may  be  a 
secondary  effect  of  the  sinking  forward  and  downward  of  the 
upper  half  of  the  trunk,  as  in  Pott's  disease  of  the  middle  of  the 
spine. 

Treatment.     The  treatment  of  secondary  deformity  would  be 
included  in  the  treatment  of  the  affection  of  which  it  is  the  result. 


232 


OR  THOPEDIC  S  UR  GER  Y. 


Manipulation,  massage,  and  breathing  exercises  may  be  employed 
in  the  treatment  of  simple  pigeon  chest.  The  tendency  is  toward 
spontaneous  cure ;  it  is  rarely  seen  in  adult  life. 

The  Funnel  Chest.     Synonym.     Pectus  excavatum. 

This  deformity  (Fig.  154)  is  the  reverse  of  the  pigeon  chest. 
The  sternum  is  depressed  and  the  lateral  diameter  of  the  thorax 
is  correspondingly  increased.  The  milder  types  of  the  affection 
in  which  there  are  one  or  more  depressions  or  hollows  in  the 


Fig.  154. 


Pectus  excavatum.    This  patient  has  ocular  torticollis  also. 

sternum  are  common.  The  extreme  form,  in  which  the  entire 
sternum  is  depressed,  is  rare.  It  is  practically  always  a  congenital 
deformity,  and  it  is  not  susceptible  to  direct  treatment. 

Minor  Deformities  of  the  Chest.  As  has  been  stated,  distor- 
tions of  the  chest  secondary  to  deformity  of  the  spine  are  often 
discovered  before  the  original  cause  is  suspected.  And  the  impor- 
tance of  the  various  minor  irregularities  of  the  chest  or  in  the 


DEFORMITIES  OF  THE  CHEST.  233 

direction  of  the  ribs  when  once  discovered  is  often  exaggerated. 
They  are  usually  the  result  of  preceding  rhachitis.  The  increase 
of  the  capacity  of  the  chest  by  appropriate  exercises  aids  in  the 
correction  of  asymmetry. 

Absence  of  Ribs.  Absence  or  defective  formation  of  ribs  is 
uncommon.  In  such  cases  there  is  usually  defective  formation  of 
the  corresponding  muscles,  and  lateral  curvature  of  the  spine  is 
a  common  accompaniment. 

Defective  Formation  of  the  Pectoral  Muscles.  Several 
instances  in  which  one  or  both  of  the  pectoral  muscles  were 
defective  or  absent  have  been  observed  at  the  Hospital  for  Rup- 
tured and  Crippled.  The  malformation  in  these  cases  caused  no 
direct  symptoms.^ 

Absence  or  Defect  of  the  Clavicle.  A  number  of  cases  of 
defective  formation  of  the  clavicle  on  one  or  both  sides  are 
recorded.  In  most  instances  a  portion  of  the  sternal  extremity 
is  present.     The  defect  appears  to  cause  but  slight  inconvenience.^ 

Acquired  Luxation  or  Subluxation  of  the  Clavicle. 

Partial  displacement  of  the  sternal  end  of  the  clavicle  is  not 
particularly  uncommon.  In  some  instances  it  is  caused  by  injury  ; 
in  others  no  cause  can  be  assigned.  Most  often  there  appears  to 
be  a  laxity  of  the  capsular  ligament  that  allows  a  displacement 
during  certain  movements  of  the  arm.  The  displacement  is 
readily  reduced,  but  the  weakness  and  insecurity  may  cause  dis- 
comfort and  disability. 

Treatment.  In  some  instances  the  displacement  may  be  pre- 
vented by  the  pressure  of  a  pad  and  truss  spring,  attached  behind 
to  the  corset  or  braces  and  passing  over  the  shoulder  close  to  the 
neck.  Such  an  appliance  is  especially  useful  if  the  displacement 
occurs  at  certain  times  only,  as  in  dressing  the  hair,  playing  on 
the  violin,  etc.  Cures  are  reported  as  the  result  of  the  injection 
of  alcohol  into  the  joint  from  time  to  time,  and  Wolff  ^  has 
operated  with  success  as  follows  :  The  joint  is  opened  by  a 
straight  incision.  A  fragment  of  bone  is  detached  from  the 
clavicle  above  and  a  similar  one  from  the  sternum  ;  these,  still 
adherent  to  the  periosteum,  are  overlapped  in  front  of  the  joint 
and  the  capsule  is  then  sutured.  As  a  rule,  the  affection  is  not 
of  particular  importance. 

1  Martiren6.    Revue  d'Orthop(5die,  May,  1903. 

-  Schornstein  and  Carpenter.    Lancet,  January  7,  1899. 

■■  Centralbl.  f.  Chlr.,  November  30, 1893. 


234 


ORTHOPEDIC  SURGERY. 


Asymmetrical  Development. 

In  normal  individuals  there  is  often  a  slight  difference  between 
the  two  halves  of  the  body,  and,  as  is  well  known,  inequality 
in  the  length  of  the  legs  is  not  at  all  uDcommon.  Inequality  of 
the  two  halves  of  the  body  may  be  congenital,  and  it  may  be 
evident  at  birth,  but  usually  it  does  not  attract  attention  until 
adolescence.  In  many  instances  this  inequality  is  a  slight 
atrophy,  the  result  of  a  cerebral  hemiplegia  of  early  childhood. 

Fig.  155. 


Hypertrophy  ot  the  right  forearm  and  hand,  due  to  congenital  ncevus. 

In  other  instances  the  inequality  may  be  due  to  congenital  hyper- 
trophy that  may  affect  the  entire  limb.  In  such  cases  the 
enlargement  may  be  due  to  an  abnormal  amount  of  normal  tissue, 
but  in  most  instances  the  hypertrophy,  which  becomes  more 
marked  with  the  growth  of  the  child,  is  caused  by  an  abnormal 
blood  supply,  a  form  of  congenital  nsevus  (Fig.  155). 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY.     235 


Table  of  Weight,  Height,  and  Circumference  of  the  Chest  in 
Childhood.    (Boas.) 


■Di^+h  /Male 

^'"•^ (Female 

„ tv^  I  Male 

6  months  .    .    .    .  |  pemale 

1  ^-.„-  (Male 

1  ye^"^ 1  Female 

(Male 
18  months.    .    .    .JFemale 
f  Md>le 

2  years j  Female 

/Male 

•    ■  ( Female 
/Male 

•  •    •    ■  ( Female 
/Male 

•  •    •    ■  (Female 
j  Male 

■  •    ■    ■  \  Female 
/Male 

■  ■    •    •  (Female 
/Male 

•  •    ■    •  (Female 
)  Male 

•  •    ■    •  1  Female 
\  Male 

•  ■    ■    •  /  Female 
/Male 

•  •    ■    ■  ( Female 
(Male 

•  •    ■    •  (Female 
(  Male 

•  •    •    •  I  Female 
(Male 

•  ■    ■    •  (Female 
(Male 

•  •    ■    ■  (Female 


Pounds. 


7.55 
7.16 
16.0 
15.5 
20.5 
19.8 
22.8 
22.0 
26.5 
25.5 
31.2 
30.0 
35.0 
34.0 
41.2 
39.8 
45.1 
43.8 
49.5 
48.0 
54.5 
52.9 
60.0 
67.5 
66.6 
64.1 
72.4 
70.3 
79.8 
81.4 
88.3 
91.2 
99.3 
100.3 
110. 08 
108.04 


Height. 


Kilos. 


3.43 
3.26 
7.26 
7.03 
9.29 
8.84 
10.35 
9.98 
12.02 
11.56 
14.14 
13.60 
15.87 
15.41 
18.71 
18.06 
20.48 
19.87 
22.44 
21.78 
24.70 
24.01 
26.58 
26.10 
30.22 
29.07 
32.83 
31.87 
36.  21 
36.90 
40.04 
4L36 
45.03 
45.50 
50.26 
49.17 


Inches. 


20.6 
20.5 
25.4 
25.0 
29.0 
28.7 
30.0 
29.7 
32.5 
32.5 
35.0 
35.0 
38. 0 
38.0 
41.7 
41.4 
44.1 
43.6 
46.2 
45.9 
48.2 
48.0 
50.1 
49.6 
52.2 
51.8 
54.0 
53.8 
55.8 
57.1 
58.2 
58.7 
61.0 
60.3 
63.0 
61.4 


Cm. 


52.5 
52.2 
64.8 
64.6 
73.8 
73.2 
76.3 
75.6 
82.8 
82.8 
89.1 
89.1 
96.7 
96.7 
106.8 
105.3 
112.0 
110.9 
117.4 
116.7 
122.3 
122, 1 
127.2 
126.0 
132.6 
131.5 
137.2 
136.6 
141.7 
145.2 
147.7 
149.2 
155.1 
153.2 
159.9 
155.9 


Chest. 


Inches. 


13.4 
13.0 
16.5 
16.1 
18.0 
17.4 
18.5 
18.0 
19.0 
18.5 
20.1 
19.8 
20.7 
20.5 
21.5 
21.0 
23.2 
22.8 
23.7 
23.3 
24.4 
23.8 
25.1 
24.5 
25.8 
24.7 
26.4 
25.8 
27.0 
26.8 
:^7.7 
28.0 
28.8 
29.2 
30.0 
30.3 


Cm. 


34.2 
33.2 

42.0 
41. U 
45.9 
44.4 
47.1 
4.^9 
48.4 
47.0 
51.1 
50.5 
52.8 
52.2 
54.8 
53.5 
59.1 
58.3 
60.6 
59.6 
62.2 
60.8 
63.9 
62.5 
65.6 
63.0 
67.2 
65.8 
68.8 
68.3 
7U.6 
71.3 
73.3 
74.1 
76.6 
79  8 


The  Functional  Pathogenesis  of  Deformity. 

Wolff's  Law.  "Every  change  in  the  form  and  function  of 
the  bones  or  of  their  function  alone  is  followed  by  certain  definite 
changes  in  their  internal  architecture,  and  equally  definite 
secondary  alterations  of  their  external  conformation,  in  accordance 
with  mathematical  laws." 

Mention  has  been  made,  and  will  be  made  again  from  time  to 
time,  of  the  adaptation  of  members  or  parts  to  abnormal  condi- 
tions, and  of  the  transformation  of  deformed  parts  to  the  normal 
when  the  improper  relations  of  weight  and  strain  have  been 
removed.  This  theory  or  law  of  functional  adaptation  has  been 
established  by  Professor  Julius  Wolff,  of  Berlin,  who  has  shown 
its  application  to  the  bones,  the  most  unyielding  structures  of  the 
body.  He  first  called  attention  to  the  fact  that  the  shape  of  a 
bone  is  the  effect  of  function.  It  is  the  effect  of  function  in  that 
if  the  work  required  of  it  had  been  different  its  shape  would  have 


236 


OB THOPEDIC  SUEGEB  Y. 


been  different.  This  function  has  shaped  not  only  the  external 
contour  but  the  internal  structure  as  well.  If  a  bone  is  broken, 
for  example,  the  neck  of  the  femur,  and  deformity  results,  the 
internal  architecture  is  no  longer  suitable  for  the  new  conditions 
of  weight  and  strain,  and  immediately  a  rearrangement  begins, 
which  finally  transforms  the  internal  structure,  not  only  in  the 
neighborhood  of  the  injury,  but  in  the  extremity  of  the  bone  also, 
to  adapt  the  deformed  part  as  well  as  may  be  to  the  work  that  is 
now  demanded  of  it. 

Fig.  156. 


Dislocated  femur,  showing  the  atrophy  and  re-arrangement  of  the  internal  structure  as 
compared  with  the  normal  (Fig.  157).    (Freiberg.) 

The  normal  bone  is  braced  most  thoroughly,  and  is  most 
resistant  at  the  points  where  most  work  is  required  of  it.  If  the 
weight  and  strain  are  for  any  reason  transferred  to  another  part, 
its  structure  becomes  hypertrophied  there,  and  correspondingly 
weakened  at  the  point  from  which  the  strain  has  been  removed. 
With  this  change  in  the  internal  structure  a  change  in  the  external 
contour  keeps  pace.  For,  according  to  this  theory,  "  the  external 
contour  represents  mathematically  simply  the  last  curve  uniting 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY.     237 

the  ends  of  the  various  trajectories  which  make  up  the  internal 
structure." 

For  the  further  exposition  of  this  theory  I  quote  from  Frei- 
berg's^ review  and  abstract  of  Wolff 's^  final  article. 

"  In  showing  that  improper  static  demands  made  upon  an 
extremity  resulted  in  the  formation  of  new  masses  of  bone  upon 
the  surface  of  the  bone  of  this  extremity,  or  that  they  produced 

Fig.  157. 


Normal  femur  from  same  subject.    (Freiberg.) 

the  disappearance  (atrophy)  of  bone  masses  according  to  the  nature 
and  degree  of  these  disturbances  in  static  requirements,  it  has  at 
once  been  shown  in  what  manner  deformities  have  their  origin. 
For  these  transformations  on  the  surface  of  bones  are  nothing 
other  than  '  deformities '  in  the  wider  or  narrower  sense  of  the 
term. 

"  Taking  genu  valgum   or  habitual  scoliosis  as  example,  the 

1  Annals  of  Surgery,  July,  1897 ;  and  American  Journal  of  the  Medical  Sciences,  December, 
1902. 

-  Die  Lehre  von  der  functionellen  Pathogenese  der  Deformitiiten,  Archiv  fur  klinische 
Chiiurgie,  Bd.  liii.  H.  4. 


238 


ORTHOPEDIC  8UR0ERY. 


development  of  a  deformity  in  the  narrow  sense  is  thus  explained. 
In  the  beginning  of  either  of  these  conditions  the  shape  of  the 
bones  is  perfectly  normal.  As  the  result  of  excessive  fatigue  in 
their  too  weak  muscles  the  patients  are  frequently  assuming  a 
faulty  position  of  limb  or  body  ;  they  seek  to  control  excessive 
excursions  of  their  joints  by  the  interference  of  the  articular 
structures  themselves  instead  of  by  muscular  activity.  The 
result  is  a  continual  alteration  in  the  static  requirements  made 
upon  the  bones  and  the  internal  architecture ;  internal  and 
external  configuration  of  the  bones  accommodate  themselves  to 
the  new  conditions.  Since,  according  to  this  reasoning,  deform- 
ities are  nothing  less  than  the  result  of  these  transformations 
which  the  external  form  of  bones  or  joints  undergo  in  accom- 


FiG.  158. 


Section  ot  femoral  head  ot  a  paralytic  idiot,  aged  thirty-five  years,  showing  the  extreme 
atrophy  caused  by  disuse.    (R.  T.  Taylor.) 

modating  itself  to  faulty  demands  made  upon  them,  it  must  be 
self-evident  that  these  deformities  are  to  be  considered  patho- 
logical only  in  the  sense  that  hypertrophy  of  the  cardiac  muscle 
in  valvular  insufficiency  is  pathological.  That  which  is  really 
pathological  is  only  the  altered  static  requirements,  the  abnormal 
mechanical  function.  Far  from  being  pathological  the  deformity 
is  the  only  suitable  or  even  possible  form  by  means  of  which 
bone  or  joint  can  withstand  the  altered  forces  bearing  upon  it;  it 
is  nature's  way  of  securing  the  greatest  possible  service  and 
strength,  under  the  new  conditions,  with  the  use  of  the  least 
possible  amount  of  material. 

"  The  pathogenesis    of    deformities    is,   therefore,    functional. 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY.     239 

Genu  valgum,  for  instance,  represents  only  the  functional  accom- 
modation of  femur,  tibia,  and  knee-joint  to  the  improper  static 
demands  made  by  the  outward  deviation  of  the  leg.  Just  so  are 
the  shapes  of  the  bones  in  club-foot  the  expressions  of  similar 
functional  accommodation  to  an  inward  rotation  of  the  foot,  or 
even,  sometimes,  an  inward  turning  of  the  whole  lower  extremity. 
The  faulty  position  of  an  extremity  under  these  circumstances  is 
to  be  regarded  rather  as  a  cause  of  the  deformity  than  as  an 
effect.  This  faulty  position  must  always  occupy  a  place  inter- 
mediate between  the  remote  causes  of  deformity  (hereditary  pre- 
disposition, habit,  muscular  weakness,  external  conditions  causing 
pressure  or  narrowing  space  of  growth),  and  the  anatomical  results 
which  these  various  remote  causes  bring  about. 

"  When  the  altered  demands  upon  an  extremity  do  not  occur 
spontaneously,  as  in  the  above  instances,  but,  on  the  other  hand, 
result  from  a  primary  disturbance  in  the  shape  of  the  bones,  due 
to  trauma  or  bone  disease  with  consequent  softening  or  destruc- 
tion of  tissue,  there  is  added  to  this  a  secondary  change  in  the 
external  configuration  of  the  bones,  and  there  is  thus  caused  a 
'  deformity  in  the  broad  sense  of  the  word.'  The  difference 
between  the  two  varieties  of  deformity,  therefore,  lies  only  in  the 
addition  of  a  second  etiological  factor  (the  trauma,  etc.)  to  the 
deformity  in  the  broad  sense.  Both  varieties  have  it  in  common 
that  the  shape  of  the  bones  and  joints  of  the  deformed  part  repre- 
sents nothing  else  than  the  expression  of  a  functional  accommo- 
dation to  the  faulty  static  demands  made  upon  it. 

"  As  a  second  example  by  means  of  which  to  explain  the  cor- 
rectness of  the  doctrine  of  functional  pathogenesis  the  author  has 
selected  scoliosis.  In  the  first  chapter  the  author  showed  in 
detail  that  the  altered  conditions  in  the  length  and  height  of  the 
transverse  processes  of  scoliotic  vertebrae  as  well  as  corresponding 
conditions  in  the  ribs  of  the  scoliotic  thorax  are  so  evident  as  not 
possibly  to  escape  notice,  and  that  they  can  be  explained  in  no 
other  way  than  as  functional  accommodation  to  the  circumstances 
of  space,  changed  and  brought  about  by  the  continual,  faulty, 
and  cramped  position  of  the  thorax ;  this  is  as  true  of  the  convex 
as  of  the  concave  side  of  the  vertebral  coin  am,  to  which  the  trans- 
verse processes  and  ribs  in  question  belong.  It  must  be  manifest 
that  changed  relations  of  one  part  of  the  skeleton  to  any  other 
part  of  the  skeleton  (as  far  as  space  conditions  are  concerned) 
necessarily  bring  about  changes  in  the  mechanical  demands  made 
upon  this  part,  and,  therefore,  changes  in  the  directions  and  values 


240  ORTHOPEDIC  SURGERY. 

of  the  pressure,  tension,  and  shearing  strains  of  each  and  every 
point  in  this  part  of  the  skeleton.  The  conclusion  thus  drawn, 
that  accommodation  to  space  means  the  same  as  accommodation 
to  function,  is  of  greatest  importance  to  the  general  doctrine  of 
functional  accommodation. 

"  The  origin  of  the  wedge-shape  of  the  scoliotic  vertebra  now 
comes  under  discussion.  It  is  assumed  by  the  majority  of  writers 
that  an  abnormal  softness  of  the  bones  is  present  in  scoliosis  by 
means  of  which  a  faulty  position  can  model  the  bodies  of  the 
vertebrae  as  it  does  in  the  case  of  rhachitic  disease  of  the  bone,  or 
as  is  really  the  case  with  the  intervertebral  disks  in  cases  of 
'  habitual  scoliosis.^  While  unsupported  by  any  pathologico- 
anatomical  investigations,  it  is  allowed  possible,  or  even  probable, 
that  such  softness  of  the  bones  plays  a  role  in  many  cases  of 
scoliosis.  It  is  certain,  however,  that  this  is  by  no  means  always 
the  case ;  as  evidenced  by  the  development  of  scoliosis  after 
empyema  in  adults,  and  the  great  exaggeration  in  adult  life  of 
very  slight  scolioses  originating  during  youth.  It  is  concluded, 
on  the  contrary,  that  the  vertebra  may  acquire  its  scoliotic  wedge- 
shape  entirely  independent  of  the  pressure  of  the  superincumbent 
weight.  Furthermore,  in  the  absence  of  any  abnormal  softness 
of  the  bones,  the  body  of  a  vertebra  may  lose  height  on  the  con- 
cave side  and  gain  the  same  on  the  convex  side  through  the 
'  tropic  stimulus  of  function '  purely  ;  being  simply  an  accommo- 
dation to  the  diminished  space  on  the  concave  side  and  increased 
room  at  the  convexity  and  the  change  of  mechanical  conditions 
consequent  thereupon. 

"  This  simple  and  natural  conception  of  the  circumstances  con- 
cerning the  scoliotic  wedge  must  obtain  credence,  especially  since 
the  old  view,  corresponding  to  the  '  pressure  theory,'  has  been 
long  ago  disproved  by  Hoffa  and  Nicoladoni — namely,  that  the 
concave  side  of  the  wedge  is  the  seat  of  atrophy,  and  that  this 
atrophy  accounts  for  the  loss  in  height  of  the  vertebral  body  on 
this  side." 

The  importance  of  Wolff's  theory,  which  shows  how  deformity 
may  be  acquired  and  how  it  may  be  avoided,  is  very  evident. 
It  is  of  equal  importance  in  indicating  the  principles  of  treatment. 
For  example,  from  the  anatomical  description  of  a  club  foot  the 
distortion  might  appear  to  be  irremediable,  but  on  this  theory 
one  feels  assured  that  if  the  foot  can  be  fixed  for  a  sufficient  time 
in  the  overcorrected  position,  the  influence  of  the  new  static  con- 
ditions will  immediately  induce  a  transformation,  not  only  in  soft 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY.     241 

parts,  but  in  the  bones  as  well,  that  will  finally  effect  a  complete 
and  absolute  cure.  So,  also,  the  correction  of  a  distorted  bone 
by  operative  means  is  at  best  but  imperfect ;  if,  however,  the 
static  conditions  have  been  changed,  nature  will  in  time  recon- 
struct the  entire  bone  so  perfectly  that  in  a  few  years  practically 
no  trace  of  the  former  distortion,  either  in  contour  or  internal 
structure,  will  be  evident.  Scoliosis  might  be  cured  as  perfectly 
as  the  club  foot  or  the  bow-leg,  were  it  possible  to  restore  as 
easily  the  normal  conditions  of  weight  and  strain. 

Atrophy  of  Bone. 

The  writings  of  Wolff  have  called  especial  attention  to  the  fact 
that  bone  is  a  living  tissue  very  readily  affected  by  changing  con- 
ditions, and  that  atrophy  or  hypertrophy  of  bone  may  be  local  or 
general,  according  to  the  change  in  functional  use  of  the  affected 
part. 

Since  the  Roentgen  ray  has  come  into  general  use  particular 
attention  has  been  called  to  the  atrophy  of  the  internal  structure 
of  bone  that  follows  lessened  use  or  disuse,  or  from  what  is  called 
trophic  disturbance  of  nutrition  from  any  cause.  For  example, 
after  fracture  or  joint  disease,  or  nervous  affections,  or  even 
slight  injuries  of  the  nature  of  sprains,  eccentric  atrophy  is 
apparent — that  is,  weakening  of  the  lamellae  of  the  spongy  por- 
tion and  decrease  in  thickness  of  the  compact  substance  of  the 
bone. 

This  atrophy  is  not  only  rapid,  but  it  may  be  widespread,  as 
proved  by  the  investigations  of  Sudeck,^  who  could  distinguish 
atrophy  of  the  bones  of  the  foot  within  six  weeks  after  fracture  of 
the  leg.  Atrophy  of  bone  is  especially  rapid  as  a  result  of  acute 
affections  of  the  joints,  corresponding  in  this  to  the  atrophy  of 
the  muscles  under  similar  conditions.  In  the  X-ray  negative 
such  atrophy  is  indicated  by  a  loss  of  clearness  of  outline  which 
is  replaced  by  a  peculiar  blur,  resembling  closely  the  infiltration 
due  to  disease. 

Weigel  has  called  attention  to  cases  in  which  general  trophic 
disturbance  of  an  entire  extremity  was  induced  by  injury  of  a 
joint.  This  disturbance  was  indicated  by  congestion,  coldness  and 
persistent  weakness  of  the  extremity,  and  it  was  always  accom- 
panied hy  marked  and  general  atrophy  of  the  bones.    Such  atrophy 

'  Fortsc.  auf  dem  Gebietp.  der  Ruiitgeiistrahlen,  Bd.  iii.  H.  6. 
16 


242  OB THOPEDIC  SURGEB T. 

may  explain  the  delay  in  recovery  after  apparently  slight  injury 
or  disease  of  a  joint  or  other  tissue.  The  treatment  should  be 
stimulative,  and  functional  use  of  the  weak  part  should  be 
encouraged  as  soon  as  possible. 

After  long-continued  disuse  the  bones  may  be  extremely  fragile. 
This  fact  must  be  borne  in  mind  when  one  attempts  to  correct 
deformity  caused  by  paralysis,  by  rheumatoid  arthritis,  and  the 
like. 


CHAPTER   Y. 

TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

Etiology.  Three  factors  are  recognized  in  the  etiology  of 
tuberculous  disease  :  the  infectious  element  (the  tubercle  bacillus), 
the  general  predisposition  of  the  patient,  and  the  local  condition 
that  favors  the  reception  and  the  growth  of  the  bacilli. 

Predisposition.  The  predisposition,  both  general  and  local,  is 
spoken  of  as  lessened  vital  resistance.  A  general  predisposition 
to  disease  may  be  inherited  or  it  may  be  acquired.  Thus,  a  his- 
tory of  tuberculosis  in  the  immediate  family  of  the  patient  is  sup- 
posed to  imply  a  lessened  resistance  to  this  form  of  disease.  In 
a  certain  proportion,  perhaps  25  per  cent,  of  the  cases,  this  in- 
herited predisposition  is  very  direct  and  positive,  but  in  the 
larger  number  the  family  history  is  as  indefinite  as  in  a  similar 
class  of  patients  under  treatment  for  any  other  form  of  ailment. 
The  acquired  predisposition  is  of  more  direct  importance  since  it 
would  include  the  lowering  of  the  vitality  due  to  improper  food 
and  improper  hygienic  surroundings  of  every  variety,  together 
with  the  greater  liability  to  depressing  diseases  and  the  more 
constant  exposure  to  tuberculous  infection  that  such  conditions 
imply.  Thus,  tuberculous  disease  of  the  bones,  as  well  as  of 
other  parts,  is  more  common  among  the  poor  of  cities  than  among 
the  more  favored  classes. 

Mode  of  Infection.  The  tubercle  bacilli  may  be  introduced  to 
the  body  by  inhalation  and  find  their  way  to  the  bronchial  glands, 
or  by  the  mouth  and  set  up  disease  in  the  mesenteric  glands, 
or,  after  infection  of  the  nasal  passages  or  neighboring  parts, 
secondary  disease  of  the  cervical  lymphatics  may  cause  the 
so-called  scrofulous  glands  of  the  neck. 

Latent  Tuberculosis.  It  may  be  assumed  that  disease  of  the 
bronchial  and  mesenteric  glands  is  not  uncommon  in  individuals 
of  apparently  perfect  health,  since  it  is  often  discovered  at 
autopsies  in  those  who  have  died  from  other  causes.  This  form 
of  glandular  disease  is  called  latent  tuberculosis,  and  it  usually 
precedes  a  local  outbreak  in  the  bone  or  elsewhere.  In  many 
instances  the  disease  may  remain  latent  and  finally  disappear,  or 
it  may  persist,  and  from   time  to  time  free  bacilli  or  bits  of  in- 


244  ORTHOPEDIC  S UB GEE  Y. 

fected  tissue  may  escape  into  the  blood  current;  by  it  they  are 
deposited  in  other  parts,  where,  under  favoring  conditions,  local 
disease  may  be  set  up.  Depression  of  the  vitality  from  any  cause 
may  be  supposed  to  favor  the  progress  of  the  glandular  disease, 
which  may  lead  to  a  dissemination  of  the  infectious  elements,  and 
at  the  same  time  it  may  lessen  the  resistance  of  other  tissues  that 
may  be  exposed  to  the  infection.  This  accounts  for  the  well- 
known  influence  of  certain  diseases,  such  as  measles  and  whooping- 
cough,  not  only  in  predisposing  to  local  tuberculous  disease,  but 
in  favoring  its  progress  when  it  is  already  established.  It  is 
possible,  also,  that  the  bacilli  that  have  found  their  way  into  the 
blood  current  more  directly,  as,  for  example,  through  wound 
infection,  may  set  up  primary  disease  of  a  bone  or  joint.  In  fact, 
it  is  stated  by  Koenig^  that  in  fourteen  of  sixty- seven  autopsies 
on  subjects  who  had  suffered  from  tuberculous  disease  of  the 
bones  and  joints,  no  other  foci  were  found  in  the  body.  In  other 
instances  the  source  of  infection  may  be  pre-existent  disease  of 
the  lungs  or  of  other  internal  organs. 

In  769  autopsies  on  children  under  twelve  years  of  age,  at  the 
Hospital  for  Children,  Great  Ormond  Street,  London,  reported 
by  G.  F.  Still,^  269  presented  tuberculous  lesions.  Of  these,  117 
were  less  than  two  years  of  age. 

The  apparent  channels  of  infection,  as  evidenced  by  the  appear- 
ance of  the  glandular  lesions,  were  as  follows  : 

Respiratory : 

Lungs 105 

Probably  lungs 33 

Ear 9 

Probably  ear 6 

153  =  57  per  cent. 
Alimentary : 

Intestines 53 

Probably  intestines 10 

63  =  23.4  per  cent. 
Other  cases : 

Bones  or  joints 5 

Fauces 2 

Uncertain 46 

53 

Northrup  and  Bovaird^  have  made  similar  observations  at  the 
New  York  Foundling  Hospital  : 

Infection  by  respiratory  tract 148 

Infection  by  mesenteric  lymph  nodes         ....       3 
Indeterminate 48 

200 

1  Deutsche  Chir.,  1900,  L.  28a,  S.  157.  2  British  Medical  Journal,  August  19, 1899. 

3  Northrup.     New  York  Medical  Journal,  February  21, 1891.    Bovaird,  ibid.,  July  1, 1899. 


TUBERCULOVS  DISEASE  .OF  THE  BONES  AND  JOINTS.      245 

In  sixteen  instances  the  process  was  confined  to  the  bronchial 
glands,  and  in  no  instance  were  these  glands  found  to  be  free  from 
disease. 

Bovaird'  has  collected  the  reported  autopsies  on  tuberculous 
children  with  reference  to  primary  intestinal  infection,  and  has 
called  attention  to  the  fact  that  the  English  observations  are  not 
in  accord  with  others  : 

Avtnnmejt        Primary  intestinal 
Autopsies.  disease. 

German 236  9  =    4  per  cent. 

French 128  0 

English 748  136  =  18        " 

American 369  5  =    1        " 

1481  150 

Haushalter,^  in  78  autopsies  upon  children  dying  from  acute 
miliary  tuberculosis,  found  in  all  but  4  disease  of  the  tracheo- 
bronchial glands.  In  44  this  disease  was  the  most  ancient  focus 
in  the  body. 

Local  Predisposition.  The  local  conditions  that  favor  the 
growth  of  the  tubercle  bacilli  may  be  induced  by  injury.  Slight 
injury  sufficient  to  cause,  for  example,  a  hemorrhage  into  the 
substance  of  the  cancellous  tissue  induces  a  local  congestion  dur- 
ing the  process  of  repair  that  provides  the  proper  soil  for  the 
growth  of  the  bacilli  when  they  are  deposited  in  its  neighborhood. 
This  has  been  proved  experimentally  by  Krause,  and  it  is  sup- 
ported by  clinical  evidence.  The  great  preponderance  of  disease 
in  the  lower  over  that  of  the  upper  extremities  in  childhood  is 
sujDposed  to  be  another  argument  in  favor  of  the  influence  of 
injury  in  the  causation  of  disease. 

In  513  of  3398  cases  of  tuberculosis  of  the  bones  and  joints 
reported  by  Hildebrand,^  Koenig,  Mikulicz,  and  Bruns  injury 
seemed  to  be  a  direct  predisposing  cause  of  the  local  disease  (16.5 
per  cent.).  A  much  higher  percentage  than  this  has  been 
assigned  by  certain  writers,  but  the  exact  relation  of  traumatism 
to  disease  can  only  be  conjectured. 

The  primary  disease  is  almost  always  in  the  newly-formed 
bone  about  an  epiphyseal  cartilage.  This  tissue  is  vulnerable ; 
it  is,  therefore,  more  exposed  to  direct  injury ;  it  is  subjected, 
also,  to  the  strain  of  motion  at  the  neighboring  joint,  and  as  the 
circulation  is  here  more  active  the  bacilli  are  more  often 
deposited  in  this  situation. 

1  Archives  of  Pediatrics,  December,  1901. 
-  Archiv.  de  Miid.  des  Enfants,  March,  1902. 
3  Deutsche  Chir.,  1902,  L.  13,  S.  168. 


246  ORTHOPEDIC  SUBGEBY. 

The  vulnerability  of  growing  bone  accounts  also  for  the  relative 
frequency  of  bone  disease  in  childhood,  as  compared  with  adult 
life.  Injury  not  only  causes  a  local  predisposition  to  disease,  but 
it  favors  its  progress  when  it  is  once  established. 

Distribution  of  the  Disease.  In  13,308  cases  of  tuberculous 
disease  of  the  bones  and  joints  treated  at  the  Hospital  for  Rup- 
tured and  Crippled  the  distribution  was,  in  order  of  frequency,  as 
follows : 

Vertebrae 5,662    =    42.5  per  cent. 

Hip-joint 4,048    =    30.5 

Other  joints 3,598    =    27.0        " 

13,308 

In  a  total  of  3561  cases  treated  at  the  Hospital  for  Ruptured 
and  Crippled  and  at  the  Vanderbilt  Clinic  during  a  period  of 
five  years,  the  distribution  was  as  follows  : 

Vertebrae 1432    =  40.2  per  cent. 

Hip-joint 1123    =  31.5  " 

Knee-joint 699    =  19.6  " 

Ankle-joint 196    =  5.5  " 

Elbow-joint 62 -i 

Shoulder-joint 42l=  3.1  " 

Wrist-joint If 

3561 

Trunk 1432    =    40.2  per  cent. 

Lower  extremities 2018    =    56.6       " 

Upper  "  Ill    =      3.1       " 

The  correspondence  between  these  two  tables  of  statistics  is 
striking,  and  the  number  of  cases  is  so  large  that  the  proportions 
may  be  accepted  as  approximately  correct  as  applied  to  the  dis- 
tribution of  the  disease  in  childhood. 

At  the  Boston  Children's  Hospital  in  a  period  of  twenty-five 
years,  1869-1893,  3820  cases  were  treated.^  The  distribution 
was  as  follows : 

Vertebrae 1964    =  51.4  per  cent. 

Hip 1402    =  36.7 

Ankle  . 300    =  7.8       " 

Knee 104    =  2.7       " 

Wrist 20i 

Shoulder 15^=  1.3       " 

Elbow 15^ 


3820 

Trunk 1964    =    51.4  per  cent. 

Lower  extremities 1806    =    47.2 

Upper         "  50    =     1.3       " 

Side  Affected.     Disease  of  the  joints  is  slightly  more  common 
on  the  right  than  on  the  left  side  of  the  body.     At  the  Hospital 

1  Report  of  the  Boston  Children's  Hospital. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.      247 

for  Ruptured  aud  Crippled  the  proportions  in  the  cases  treated 
during  a  recent  period  of  ten  years  are  as  follows  : 

Hip,  right 53  per  cent. 

Knee,  right 55       " 

Ankle,  right 50       " 

Shoulder,  right ^       i 

Elbow,  right 60       " 

It  has  been  stated  that  one  of  the  explanations  of  the  great 
preponderance  of  the  disease  of  the  lower  over  the  upper  extremity 
is  the  greater  liability  to  injury.  The  same  explanation  has  been 
advanced  to  account  for  the  greater  frequency  of  disease  on  the 
right  side,  which  is  more  marked  in  the  upper  than  in  the  lower 
extremity,  because  the  right  arm  is  more  liable  to  overwork  as 
well  as  to  injury. 

Sex.  Tuberculous  disease  of  the  joints  is  somewhat  more 
common  among  males  than  females. 

Of  3822  cases  of  Pott's  disease  treated  at  the  Hospital  for 
Ruptured  and  Crippled,  2037,  or  53  per  cent.,  were  in  males. 

Of  3307  cases  of  disease  of  the  hip-joint  treated  at  the  same 
institution,  1731,  or  52.3  per  cent,  were  in  males. 

Of  1218  cases  of  disease  of  the  knee-joint,  combined  statistics 
of  Koenig  and  Gibney,  703,  or  57.6  per  cent.,  were  in  males. 

Age.  In  5461  cases  of  tuberculous  disease  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled,  about  seven-eighths  of  the 
patients  were  less  than  fourteen  years  of  age. 

/■  vertebrae,      87.7  percent. 

Less  than  14  years  of  age -<  hip,  88.2 

tother  joints,  71.7       " 

/-vertebrae,        7.7  percent. 
Between  14  and  21  years  of  age .       .       .       .-jhip,  9.2 

f-other  joints,  10.7       " 

/-vertebrae,        4.5  per  cent. 

More  than  21  years  of  age -^  hip,  2.5 

vother  joints,  17. 51      " 

Of  1259  cases  of  Pott's  disease  treated  recently  at  the  same 
institution,  1075,  or  85  per  cent,  of  the  patients,  were  in  the  first 
decade ;  50  per  cent,  were  three  to  five  years  of  age,  inclusive,  at 
the  inception  of  the  disease. 

In  1000  cases  of  disease  of  the  hip-joint  the  ages  of  the  patients 
correspond  closely  to  these;  87.2  per  cent,  were  in  the  first 
decade,  and  45.2  per  cent,  were  from  three  to  five  years  of  age, 
inclusive. 

In  1000  cases  of  disease  of  the  knee-joint,  75  per  cent,  were  in 

1  Knight.    Orthopedia. 


248 


ORTHOPEDIC  SURGERY. 


the  first  decade  aud  40  per  cent,  were  from  three  to  five  years, 
inclusive. 

In  339  cases  of  the  ankle-joint,  70  per  cent,  were  in  the  first 
decade  and  but  35  per  cent,  were  included  within  the  three  years. 

The  distribution  of  the  disease  and  its  relative  frequency  at  the 
different  ages  is  shown  by  Alfer's  table  of  statistics  from  Tren- 
delenburg's clinic  at  Bonn.^ 


j  0-5 

5-10 

10-15 

15-20 

20-25  25-30 

30-35 

35-40  40-45  45-50 

50-55  55-60  60-65 

65-70 

Total 

Vertebrse 

89 

59 

32 

23 

9 

10 

3 

6 

3 

1 

4 

0 

0 

0 

239 

Hip 

SS 

59 

43 

46 

9 

11 

6 

(1 

4 

1 

1 

3 

0 

0 

241 

Knee 

47 

52 

47 

37 

20 

11 

23 

11 

11 

3 

2 

8 

6 

3 

281 

Ankle 

5 

9 

10 

5 

2 

1 

1 

3 

2 

0 

3 

0 

2 

0 

43 

Shoulder 

0 

2 

2 

6 

3 

5 

3 

1 

1 

2 

2 

1 

0 

0 

28 

Elbow 

7 

14 

14 

21 

12 

9 

6 

5 

9 

8 

5 

2 

2 

0 

114 

Wrist 

1 

0 

0 

1 

5 

0 

0 

3 

1 

3 

2 

1 

3 

0 

20 

Total 

207 

195 

148  1  139 

i 

60 

47 

42 

29 

31 

18 

19 

15 

13 

3 

966 

This  table  illustrates  the  well-known  fact  that  disease  of  the 
upper  extremity,  relatively  infrequent  at  all  ages,  is  proportion- 
ately far  more  common  in  adult  life  than  is  disease  of  the  lower 
extremity.  Of  the  joints  of  the  lower  extremity,  the  knee  and 
the  ankle  are  proportionately  more  often  diseased  in  later  life 
than  is  the  hip. 

Pathology.  When  the  bacilli  are  deposited  in  a  part,  the  irri- 
tation of  their  toxins  causes  a  proliferation  of  the  fixed  cells 
which  lie  in  direct  contact  with  the  germs,  and  about  these  a  ring 
of  leucocytes  forms.  The  bacilli,  the  epithelioid  cells  including 
often  one  or  more  giant  cells,  together  with  the  surrounding  leu- 
cocytes, constitute  the  visible  tubercle  of  bone,  a  minute  grayish 
speck  in  the  cancellous  structure.  The  central  cells  about  the 
bacilli,  increasing  in  number,  deprived  of  nourishment  and 
poisoned  by  the  toxins,  die  and  are  disintegrated  to  granular 
material,  "  caseate,"  and  the  tubercle  changes  to  a  yellow  color ; 
but  the  bacilli,  multiplying  and  escaping,  form  new  tubercles 
about  the  original  focus,  which  coalesce  as  the  area  of  the  disease 
enlarges.  Meanwhile  the  surrounding  tissue  becomes  congested, 
as  the  result  of  the  irritation,  and  the  fixed  cells  become  organized, 
or  partly  organized,  into  a  feeble,  ill-nourished  form  of  granula- 
tion tissue,  representing  the  effort  of  the  part  to  shut  out  and  to 
expel  the  foreign  substances  formed  by  the  disease.  Or,  if  this 
local  resistance  is  effective,  the  cells  become  actually  organized 
into  firm  granulations  which  surround  and  destroy  the  germs,  and 


1  Beit,  zurklin.  Chir.,  1891,  Bd.  viii.  H.  2. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.      249 

then  are  further  transformed  into  scar  tissue.  But  in  most 
instances,  either  because  the  irritation  is  insufficient  or  because  of 
the  deficient  vitality  of  the  jsart,  the  granulations  are  feeble  and 
unstable,  and  they  in  turn  becoming  infected  by  the  multiplying 
bacilli  serve  only  to  extend  the  area  of  the  disease.  This  granu- 
lation tissue,  before  and  after  the  stage  of  infection,  absorbs  and 
destroys  the  bone.  If  the  progress  of  the  disease  is  slow,  the 
cancellous  structure  is  completely  absorbed  or  is  represented  only 
by  bone  sand,  but  if  the  disease  infiltrates  the  bone  more  rapidly 
it  may  destroy  its  vitality  while  its  structure  is  still  retained,  and 
a  sequestrum  is  formed.  Such  sequestra,  consisting  of  rounded, 
yellow,  crumbling  masses  of  cancellous  structure,  from  the  size  of 
a  peanut  to  a  hazelnut,  are  especially  common  in  epiphyseal  disease 
of  childhood.  In  rare  instances  wedge-shaped  sequestra  are 
found  with  the  base  at  the  periphery  of  the  epiphysis.  These 
are  supposed  to  be  caused  by  the  lodging  of  an  infected  embolus 
in  a  terminal  vessel,  thus  cutting  off  the  blood  supply. 

By  the  formation  of  new  tubercles  at  the  periphery,  and  by 
the  caseation  of  material  in  the  centre  of  the  diseased  area,  a 
cavity  in  the  bone  is  formed,  containing  the  debris  of  the  granu- 
lation tissue  and  often  sequestra  of  larger  or  smaller  size,  and  a 
variable  amount  of  fluid,  made  up  of  serum  and  leucocytes,  that 
has  exuded  from  the  surrounding  granulations.  The  walls  of 
this  cavity  are  formed  by  the  tissue  in  which  the  disease  is  active ; 
the  inner  layer  containing  the  tubercles  in  the  various  stages  of 
formation  and  decay,  the  outer,  composed  of  feeble,  ill-nourished, 
granulation  tissue  as  yet  not  infected,  and  beyond  this  the  softened 
and  infiltrated  bone.  If  the  disease  has  ceased  to  progress  in 
any  direction,  the  granulations  contain  more  bloodvessels,  they 
are  of  firmer  consistency  and  more  perfectly  organized,  and  the 
substance  of  the  bone  is  harder,  showing  the  evidence  of  repair. 

One  termination  of  epiphyseal  disease  is  by  enclosure  of  the 
focus  by  resistant  granulations,  behind  which  the  bone  solidifies 
and  shuts  in  the  disease,  or,  in  favorable  cases  in  which  its  area 
is  small,  completely  absorbing  and  replacing  it  by  scar  tissue. 

Extra-articular  Disease.  As  a  rule,  the  tendency  of  the  process 
is  to  expand  and  to  force  an  opening  through  the  cortex  of  the 
bone  to  the  exterior.  In  certain  cases  this  opening  may  form 
outside  the  capsule  of  the  joint,  and  through  it  the  products  of 
the  disease  may  be  discharged  into  the  overlying  tissues,  forming 
a  tuberculous  abscess.  Here,  the  same  process  of  infection  and 
extension  of  the  area  of  disease  continues,  but  more  rapidly  than 


250  ORTHOPEDIC  SUBGER  Y. 

when  it  was  confined  within  the  bone.  The  surfaces  of  the  muscles 
and  fascia  are  infected,  and  are  covered  with  an  abscess  mem- 
brane of  violet  or  grayish-yellow  color,  made  up  of  tubercular 
tissue  and  masses  of  fibrin,  lyiug  upon  and  loosely  attached  to 
the  outer  inflammatory  or  healthy  granulations. 

The  cavity  of  the  abscess  is  distended  with  tuberculous  pus 
usually  of  a  thin  consistency,  composed  of  serous  exudation, 
leucocytes,  fibrin,  masses  of  degenerated  tissue  and  fragments  of 
bone  or  bone  sand.  It  is  commonly  of  a  whitish  color,  occasion- 
ally reddish  from  mixture  with  blood,  and,  in  the  later  stages, 
yellow  and  serous- like.  The  abscess  enlarges  in  the  direction  of 
least  resistance,  and  in  most  instances  finally  perforates  the  skin 
by  one  or  more  openings  through  which  its  contents  are  dis- 
charged. Or,  its  boundaries  may  cease  to  extend,  its  contents 
may  be  absorbed,  adhesions  may  form  between  its  walls,  and  a 
spontaneous  cure  is  effected.  Extra-articular  disease,  without  ulti- 
mate involvement  of  the  joint,  is  unusual.  It  is  more  common  at 
those  joints  like  the  knee,  elbow,  and  ankle,  in  which  the  bones 
are  superficial ;  it  is  very  uncommon  at  the  hip-joint,  aud  it  is 
practically  impossible  in  disease  of  the  spine. 

Perforation  of  the  Joint.  Usually  the  tuberculous  process  within 
the  epiphysis,  enlarging  its  area,  comes  into  contact  with  cartilage, 
and,  perforating  this,  finds  its  way  into  the  joint.  While  the 
disease  is  still  confined  within  the  bone,  the  tissues  within  the 
joint  are  involved  in  a  sympathetic  irritation  or  inflammation. 
The  synovial  membrane  becomes  congested  and  hypertrophied ; 
the  synovial  fluid  is  increased  and  changed  in  quality ;  fibrin 
forms  and  is  deposited  upon  the  cartilage  and  upon  the  lining 
membrane  of  the  capsule.  It  is  stated  by  Koenig  that  the 
organization  of  these  fibrinous  deposits  upon  the  cartilage  plays 
an  important  part  in  its  destruction,  even  when  actual  tuberculous 
disease  is  absent.  As  a  result  of  the  sympathetic  inflammation 
within  the  joint,  adhesions  may  form  which  may  limit  the  area 
of  the  tuberculous  disease  and  retard  its  progress  after  perforation 
has  taken  place.  This  process  is  similar  to  the  inflammatory 
changes  in  the  pleura  caused  by  the  underlying  tuberculous 
disease. 

When  the  disease  comes  in  contact  with  the  cartilage  it  disin- 
tegrates ;  the  tuberculous  granulations  breaking  through  and 
spreading  over  its  surface  destroy  it  in  piecemeal,  or,  advancing 
beneath  it,  separate  it  from  the  bone  in  large,  necrotic  fragments. 
The    synovial    membrane    becomes    thickened    and    infiltrated, 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.      251 

numerous  tubercles  appear  upon  its  surface,  which  undergo  the 
secondary  changes  that  have  been  described,  and  the  joint 
becomes,  practically  speaking,  an  abscess  cavity.  The  surfaces 
of  the  bones  are  disintegrated  by  the  disease,  and  the  destruction 
is  hastened  by  the  pressure  and  friction  due  to  muscular  spasm 
and  to  functional  use.  The  thickened  capsule,  distended  by  the 
fluid  and  solid  products  of  the  disease,  is  usually  perforated,  and 
a  secondary  abscess,  communicating  with  it,  is  formed  in  the  sur- 
rounding tissues.  As  results  of  the  disease,  secondary  changes 
appear  in  the  neighboring  parts.  The  irritation  of  the  periosteum, 
if  the  disease  is  of  a  quiescent  type,  may  induce  the  formation  of 
irregular  layers  of  bone  or  osteophytes  about  the  joint.  A  new 
formation  of  connective  tissue  proceeding  from  the  layer  of  granu- 
lations that  surround  the  disease  may  extend  to  the  muscles  and 
tendon  sheaths,  binding  them  together,  and  causing  limitation  of 
motion.  The  newly-formed  connective  tissue  may  be  very  vas- 
cular and  irregular  in  formation,  and  intermixed  with  it  may  be 
masses  of  gelatinous  or  myxomatous  tissue.  This,  according  to 
Krause,  is  due  to  the  venous  stasis  and  oedematous  infiltration 
caused  by  the  pressure  of  the  capsular  contents  and  extracapsular 
proliferation  of  granulation  tissue.  These  changes  in  the  appear- 
ance and  in  the  consistency  of  the  tissues  about  the  joint  are 
characteristic  of  the  so-called  white  swelling. 

Other  Forms  of  Tuberculous  Disease  of  Joints.  All  of  the 
German  writers  describe  forms  of  primary  synovial  disease,  its 
frequency  varying  from  16  to  35  per  cent,  of  the  cases.  It  is 
more  common  in  adult  life  than  in  childhood,  and  at  the  knee 
than  at  other  joints.  But  Nichols^  states  that  he  has  examined 
120  tuberculous  joints,  and  has  found  in  every  instance  one  or 
more  foci  in  the  bone  that  apparently  preceded  the  disease  in  the 
joint. 

Whatever  may  have  been  its  origin,  from  the  clinical  stand- 
point, one  must  recognize  a  form  of  disease  in  which  the  symp- 
toms differ  from  the  ordinary  osteal  type.  It  begins  as  a 
chronic  synovitis,  although  the  tissues  are  more  thickened  and 
infiltrated  than  in  simple  synovitis,  and  the  muscular  atrophy  is 
more  marked.  Reflex  spasm  and  limitation  of  motion  are  slight, 
and  the  symptoms  are  rather  discomfort  and  fatigue  after  exertion 
than  actual  pain.  After  many  months  or  years,  when  it  may  be 
assumed  the  bones  arc  involved,  the  characteristic  symptoms  of 

'  Transactions  American  Orthopedic  Association,  vol.  xi. 


252 


ORTHOPEDIC  SURGERY. 


tuberculous  disease  appear.  In  one  form  of  synovial  disease  the 
amount  of  effused  fluid  is  large,  and  it  is  clear  and  serous-like  in 
character  — hydrops  tuberculosus  ;  but  usually  it  is  cloudy,  and  it 
may  be  purulent  in  character. 

As  has  been  stated,  Koenig  lays  stress  upon  the  important  part 
played  by  fibrin  in  the  changes  that  take  place  within  a  joint. 
Fibrin  deposited  from  the  effused  fluid  forms  in  successive  layers 
upon  the  cartilage.  Into  this  fibrin  vessels  grow  from  the 
hypertrophied  and  infected  synovial  membrane,  destroying  the 
cartilage  together  with  the  underlying  bone.  If  the  synovial 
disease  is  primary  the  bone  is  destroyed  superficially,  but  if  it  is 
secondary  to  synovitis  disease  within  the  epiphysis  it  is  usually 
more  extensive.  Synovial  tuberculosis  is  essentially  a  chronic 
affection  and  is  often  mistaken  for  simple  or  so-called  rheumatic 
synovitis. 

Arborescent  Ssmovial  Tuberculosis.  In  this  form  the  interior  of 
the  joint  is  covered  with  villous  proliferations  of  the  synovial 
membrane.  It  is  not  a  distinct  disease,  but  is  an  irritative  hyper- 
trophy that  is  present  in  syphilitic  and  rheumatic  as  well  as  in 
tuberculous  joints.  Its  especial  interest  lies  in  the  fact  that  the 
hypertrophied  synovial  growths  may  cause  mechanical  interfer- 
ence with  the  function  of  the  joint. 

Fig.  159. 


Lipoma  arborescens.    (Painter  and  Erving.) 

Lipoma  Arborescens.  Arborescent  villous  proliferations  are 
formed  of  adipose  and  fibrous  tissue  covered  with  a  layer  of  round 
cells.  The  hypertrophied  masses  which  project  into  the  joint  are 
often  of  large  size,  attached  to  the  synovial  membrane  by  a 
smaller  pedicle.     They  are  single  or  multiple,  and  vary  in  color 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.       253 

from  yellow  to  deep  red.  They  may  be  of  a  soft  or  firm  consist- 
ency. In  this  form  of  disease,  as  in  that  described  in  the  pre- 
ceding section,  there  is  usually  pain,  limitation  of  motion ;  often 
the  swollen  joint  is  irregular  in  outline;  the  hypertrophied  syno- 
vial prolongations  are  sometimes  apparent  on  palpation.^  The 
exact  diagnosis  is  usually  made  only  after  an  exploratory  incision, 
and  iu  such  an  event  the  removal  of  the  larger  prolongation 
would  be  indicated.  The  outcome  depends,  of  course,  upon  the 
cause,  the  hypertrophy  depending  usually  on  an  underlying  tuber- 
culous, syphilitic,  or  so-called  rheumatoid  disease.  In  the  in- 
stances in  which  the  hypertrophied  tissue  is  in  itself  the  cause  of 
the  disability,  cure  may  follow  its  removal. 

Rice  Bodies.  Rice  bodies  are  numerous  small,  grayish-white 
bodies  resembling  cucumber  seeds  that  are  found  in  certain  forms 
of  synovial  disease,  and  particularly  in  tuberculosis  of  tendon 
sheaths.  They  are  formed  of  fragments  detached  from  the  pro- 
liferating synovial  membrane  and  possibly  of  simple  fibrin,  which, 
under  the  influence  of  pressure  and  attrition  in  the  movements  of 
the  joint  or  of  the  tendon,  assume  the  characteristic  shape  and 
appearance.  These  bodies,  within  a  tendon  sheath  or  joint,  cause 
a  peculiar  creaking,  perceptible  to  the  touch  when  the  part  is 
moved. 

Dry  Caries.  Caries  Sicca.  In  this  form  of  disease,  which  is 
apparently  primarily  synovial,  there  is  but  little  formation  of 
fluid,  and  there  is  but  little  tendency  toward  cheesy  degeneration 
of  the  tuberculous  products.  The  infected  granulations  destroy 
the  bone  without  forming  sequestra,  and  usually  without  sup- 
puration. This  form  more  often  occurs  at  the  shoulder-joint, 
and  it  is  characterized  by  marked  limitation  of  motion,  extreme 
atrophy  of  the  surrounding  parts,  and  sometimes  by  forward 
displacement  of  the  partly  destroyed  head  of  the  humerus  that 
may  be  mistaken  for  a  primary  dislocation. 

Septic  Infection.  When  a  tuberculous  abscess  has  opened  spon- 
taneously, or  when  it  has  been  incised,  infection  with  pyogenic 
germs  is  common,  and  it  occasionally  occurs  before  a  communi- 
cation with  the  exterior  has  been  established.  After  such  infec- 
tion the  surrounding  tissues  become  infiltrated,  reddened,  and 
sensitive  to  pressure.  The  discharge  is  greatly  increased  in 
quantity  and  changed  in  quality.  The  local  pain  and  discomfort 
are  aggravated  ;   if  the  joint  is  Involved   the  destruction  of  the 

'  Painter  and  Erving.    Boston  Med.  and  Surg.  Journal,  March  19,  1903. 


254  OB THOPEDIC  S  UB GEB  Y. 

bone  goes  on  with  increased  rapidity,  and  the  constitutional  effects 
of  pyogenic  infection  appear.  If  the  area  of  the  abscess  is  small 
and  if  the  drainage  is  efficient,  this  accident  is  of  slight  impor- 
tance, and  it  may  even  exercise  a  beneficial  effect  in  stimulating 
the  circulation  and  dissolving  the  effused  material  about  a  joint. 
But  if  the  abscess  has  burrowed  widely  into  surrounding  tissues 
and  if  it  communicates  with  an  important  joint  it  is  a  dangerous 
complication  ;  in  fact,  the  greatest  direct  danger  of  tuberculous 
joint  disease.  Persistent  suppuration  exhausts  the  patient,  and 
by  lessening  the  vital  resistance  it  favors  the  local  advance  of  the 
tuberculous  disease  and  its  general  dissemination.  It  is  in  this 
class  of  cases  that  amyloid  degeneration  of  the  internal  organs  is 
common,  induced  not  by  tuberculous  disease,  but  by  the  secondary 
infection  and  its  consequences. 

Repair.  Repair  in  tuberculous  disease  may  be  accomplished 
by  the  absorption,  ejection,  or  enclosure  of  the  disease.  The 
process  of  repair  usually  accompanies  the  advance  of  the  destruc- 
tive process,  and  examples  of  the  three  methods  of  cure  may  be 
found  in  a  single  joint. 

The  curative  agent  is  the  granulation  tissue  which  forms  about 
the  area  of  disease,  and  which,  finally  becoming  sufficiently 
organized  to  resist  the  infection  of  the  bacilli,  solidifies  into 
fibrous  tissue.  In  those  cases  in  which  the  disease  is  not  absorbed 
or  completely  thrown  oft'  in  the  abscess  formation,  but  is  enclosed,  it 
becomes  quiescent.  In  such  cases  traumatism,  when,  for  example, 
the  surrounding  adhesions  are  broken  down  in  the  attempt  to 
rectify  deformity  or  to  overcome  anchylosis,  may  cause  local 
recurrence  of  the  disease. 

Prognosis.  The  prognosis  will  be  considered  more  particularly 
in  the  sections  on  disease  of  special  parts.  The  danger  to  life  is 
direct  and  indirect,  and  this  varies  greatly  with  the  part  that  is 
affected  and  with  the  age  of  the  patient. 

In  disease  of  the  spine  the  direct  danger  to  life  is  greater  than 
in  joint  disease,  because  of  its  situation,  since  it  may  involve  the 
spinal  cord  or  extend  to  the  important  organs  in  the  neighborhood. 
Abscess  may  in  rare  instances,  merely  by  its  size  and  situation, 
endanger  life,  and  when  infected  it  is  far  more  dangerous  because 
of  the  difficulty  in  providing  efficient  drainage.  The  influence  of 
deformity  and  its  effect  in  compressing  the  internal  organs  and  thus 
interfering  with  the  vital  functions  is  another  more  remote  element 
of  danger  in  disease  in  this  situation. 

The  danger  to  life  from  disease  of  the  joints  is  in  proportion  to  their 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.       255 

importance.  In  rare  instances  it  may  extend  from  the  epiphysis  to 
the  shaft  of  a  bone  and  set  up  an  extensive  osteomyelitis ;  or  the 
patient  may  be  weakened  by  the  suffering  caused  by  active  disease, 
but,  as  has  been  stated,  the  most  direct  and  constant  danger  is  from 
prolonged  suppuration  that  follows  septic  infection.  Danger  from 
this  source  is  much  greater  at  the  hip-joint  than  at  the  ankle  or 
elbow,  for  example,  because  of  the  greater  difficulty  in  preventing 
the  burrowing  of  pus  when  infection  has  occurred. 

The  indirect  danger  of  tuberculous  disease  is  its  dissemination  to 
more  important  organs.  But  it  by  no  means  follows  that  the 
disease  of  the  joint  is  the  source  of  the  general  infection.  For,  as 
has  been  stated,  it  may  be  inferred  that  nearly  every  patient  with 
joint  disease  has  also  disease  of  the  lymphatic  glands,  and  in  a  small 
proportion  of  the  cases  there  may  be  active  disease  of  other  impor- 
tant organs  as  well.  Tuberculosis  of  the  lungs,  for  example,  is 
often  present  in  the  adult  before  the  local  outbreak  in  the  joint 
appears,  and  it  is  in  great  degree  because  of  this  liability  to  disease 
of  the  lungs  that  the  prognosis  of  joint  disease  becomes  progres- 
sively worse  with  the  age  of  the  patient. 

This  point  is  illustrated  by  the  statistics  of  Koenig  and  Bruns 
on  the  final  results  of  disease  of  the  knee  and  hip-joints,  to  which 
attention  will  be  called  again  in  the  special  sections.  In  Koenig's 
cases  of  disease  of  the  knee-joint  the  influence  of  age  upon  the 
death-rate  is  illustrated  by  the  following  table  : 

Less  than  15  years  of  age 20  per  cent. 

From  16  to  30  years 24        " 

"      30  to  40      •' !  44        " 

More  than  40      " 60        " 

In  Bruns'  statistics  the  death-rate  was  of  patients  in  the  first 
decade,  36  per  cent.  ;  in  the  second  decade,  44  per  cent.  ;  older 
than  this,  72  per  cent. 

The  cure  of  latent  tuberculosis  in  the  lymph  nodes  as  well  as 
of  active  disease  of  the  lungs  or  bones  depends  upon  the  vital 
resistance  of  the  patient.  This  vital  resistance  is  lessened  by 
pain,  by  confinement  and  lack  of  exercise.  It  is  directly  impaired 
by  the  exhausting  suppuration  and  by  the  poisoning  of  the  toxins 
incidental  to  septic  infection.  Under  these  conditions  the  local 
disease  advances  and  a  general  dissemination  is  more  probable. 
This  accounts  for  the  fact  that  death  from  general  tuberculous 
infection  is  much  more  common  in  this  class  than  when  suppura- 
tion has  been  slight  or  absent.  This  point  is  again  illustrated 
by  the  statistics  referred  to.  The  death-rate  in  the  cases  of  dis- 
ease at  the  knee  without  abscess  was  25  per  cent.,  with  abscess 


256  OB THOPEDIC  SURGEB  Y. 

46  per  cent.  Death-rate  in  cases  of  disease  at  the  hip  with 
abscess  52  per  cent.,  without  abscess  23  per  cent. 

It  is  probable  that  tuberculosis  may  be  disseminated  by  opera- 
tion upon  tuberculous  joints,  although  the  evidence  upon  this 
point  is  vague  and  conflicting.  Gibney,  contrasting  two  equal 
periods  of  thirteen  years  of  service  at  the  Hospital  for  Ruptured 
and  Crippled,  in  the  first  of  which  no  operations  were  performed 
on  tuberculous  subjects,  states  that  in  his  opinion  the  deaths  from 
this  source  have  been  proportionately  no  greater  during  the  period 
of  active  surgical  intervention  than  before.  And  an  investiga- 
tion of  the  causes  of  deaths  among  the  patients  treated  at  the 
New  York  Orthopedic  Dispensary  and  Hospital  during  a  period 
of  twenty  years  showed  that  at  least  25  per  cent,  of  these  were 
due  to  tuberculous  meningitis.^  During  this  period  there  had 
been,  practically  speaking,  no  operative  intervention,  yet  the 
proportion  of  deaths  from  this  cause  is  certainly  as  great  as  in 
any  statistics  that  have  been  reported.  It  would  appear,  then, 
that  the  danger  of  dissemination  is  not  sufficient  to  deter  one 
from  performing  any  operation  that  seems  to  be  indicated  by  the 
character  of  the  local  disease  or  by  the  general  condition  of  the 
patient. 

Diagnosis.  Diagnosis  is  considered  at  length  in  the  sections 
on  diseases  of  the  special  joints.  The  tuberculin  test,  although  of 
some  importance  from  the  negative  standpoint,  is  of  no  par- 
ticular value  as  establishing  a  diagnosis  of  joint  disease,  for  the 
reason  that  tuberculous  disease  of  the  lymph  glands  is  so  com- 
mon even  among  those  whose  joints  are  free  from  disease.  For 
the  same  reason  it  is  valueless  as  a  test  of  cure.  This  is  illus- 
trated by  the  investigations  of  Frazier  and  Biggs^  of  patients 
clinically  cured  of  local  tuberculosis,  some  by  operative  means. 
In  78  per  cent,  of  these  a  positive  reaction  to  tuberculin  was 
obtained.  The  X-ray  is  often  of  value  in  demonstrating  the 
effects  of  disease,  and  in  certain  instances  it  may  indicate  its 
exact  locality  and  extent.  As  a  means  of  early  diagnosis  of 
joint  disease  in  young  subjects,  however,  it  is  of  little  importance 
as  compared  to  the  physical  signs,  because  of  the  non-development 
of  the  bony  structure  of  the  epiphysis,  which  alone  appears  in 
the  negative. 

Treatment.  From  what  has  been  stated  of  the  causes  of  dis- 
ease it  f(jllows  that  the  general  treatment  should  include,  if  possible, 

1  Personal  communication  from  Dr.  David  Bovaird. 
-  University  Medical  Magazine,  February,  1901. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.       257 

a  change  in  the  hygienic  conditions,  relief  from  the  danger  of 
further  infection,  pure  air,  and  proper  food.  These  are  as  essen- 
tial in  the  treatment  of  tuberculosis  of  the  bones  as  of  other  parts. 
The  importance  of  the  constitutional  treatment  of  tuberculous 
disease,  more  particularly  the  proper  environment  in  which  the 
greater  part  of  the  day  and  even  the  night  may  be  passed  in 
the  open  air,  can  hardly  be  exaggerated. 

As  far  as  the  cure  of  local  disease  is  concerned,  no  treatment 
can  be  as  effective  as  the  prompt  and  thorough  removal  of  the 
focus  of  disease,  while  it  is  yet  limited  in  extent,  and  before  the 
joint  has  become  involved.  This  is  practicable,  however,  in  but 
a  small  proportion  of  the  cases  in  childhood,  because  it  is  usually 
impossible  to  locate  the  disease  accurately  and  impossible  to 
remove  it  without  sacrificing  much  of  the  healthy  bone  upon 
which  the  future  usefulness  of  the  part  depends.  At  one  time 
early  operation,  even  comj)lete  excision  of  the  joint,  was  justified 
on  the  plea  that  the  disease  might  thus  be  eradicated.  But  now 
that  it  is  known  that  in  nearly  all  cases  ottier  tuberculous  foci 
exist  in  the  body,  and  as  the  functional  results  after  these  early 
operations  are  far  inferior  to  those  attained  under  conservative 
treatment,  early  excisions  are  limited  to  the  adolescent  or  adult 
cases.  For  in  this  class  growth  has  been  attained  and  the 
economic  conditions  require  that  the  period  of  disability  should 
be  as  short  as  possible.  In  this  class,  also,  early  exploratory  opera- 
tions are  often  indicated,  sometimes  for  the  purpose  of  establish- 
ing the  diagnosis,  and  if  the  disease  is  of  the  synovial  type 
the  removal  of  projecting  folds  of  hypertrophied  tissue  and  the 
direct  application  of  irritants,  for  example,  of  pure  carbolic  acid^ 
may  be  of  service.  Brace  treatment  is  conducted  with  the  aim  of 
relieving  the  part  of  function — that  is  to  say,  from  strain  and 
injury.  Functional  use  of  a  diseased  joint  delays  natural  repair, 
since  it  causes  pain  and  thus  reduces  the  reparative  force,  while  it 
stimulates  the  disease  and  increases  its  destructive  action.  The 
details  of  treatment  will  be  described  in  the  consideration  of  dis- 
ease of  special  joints. 

Treatment  by  Drugs.  The  administration  of  drugs  occupies  a 
very  subordinate  place  in  treatment,  since  it  is  not  believed  that 
any  drug  exercises  a  direct  action  upon  the  local  disease  in  the 
bone. 

Cod-liver  oil,  the  hypophosphites,  the  various  preparations  of 
iron  or  other  tonics  may  be  given  at  certain  times  with  benefit, 
but  the  continuous  administration  of  medicine  during  the  years 

17 


258  OE THOPEDIC  S  UE  GEE  Y. 

that  are  required  to  complete  a  cure  is,  of  course,  out  of  the 
question. 

Local  Applications.  Iodoform.  Iodoform  is  supposed  to 
exercise  a  direct  germicidal  action  and  also  to  stimulate  the 
formation  of  the  granulations  that  cast  off  or  absorb  the  tuber- 
culous products  and  then  become  transformed  into  fibrous  tissue. 
At  one  time  direct  injection  of  the  remedy  into  the  bones  was 
advocated,  but  this  has  now  been  abandoned,  and  its  use  is  prac- 
tically limited  to  the  treatment  of  tuberculous  abscesses  and 
certain  forms  of  synovial  tuberculosis.  Iodoform  is  ordinarily 
employed  in  an  emulsion  with  glycerin  or  oil,  10  c.c.  of  10  per 
cent,  mixture  being  injected  at  intervals  of  two  or  more  weeks. 
Several  deaths  from  iodoform  poisoning  have  beea  reported,  but 
injections  of  this  quantity  of  the  drug  are  apparently  free  from 
danger. 

Carbolic  Acid.  Carbolic  acid  in  dilute  solutions  was  at  one 
time  injected  into  tuberculous  cavities,  but  its  use  has  been  gen- 
erally discontinued  because  of  the  danger  of  poisoning.  Recently 
Phelps  has  advocated  the  use  of  pure  carbolic  acid  in  the  treat- 
ment of  tuberculous  abscesses  and  sinuses.  This  is  injected  into 
the  fistulse  or  into  the  abscess  cavity,  which  has  been  opened,  and 
is  allowed  to  remain  for  about  a  minute,  when  it  is  neutralized 
by  copious  injections  of  alcohol,  after  which  the  part  is  thoroughly 
cleansed  by  salt  solution.  Carbolic  acid  doubtless  acts  as  a 
caustic,  destroying  the  infected  granulations  and  stimulating  the 
reparative  processes.  Other  remedies  of  this  class,  for  example, 
tincture  of  iodine,  chloride  of  zinc,  actual  cautery  and  the  like, 
are  also  used,  and  in  certain  cases  with  benefit.  In  the  treatment 
of  tuberculous  ulcerations  ichthyol,  balsam  of  Peru,  and  iodoform 
are  among  the  drugs  employed.  Balsam  of  Peru  dissolved  in 
castor  oil  of  a  strength  of  about  10  per  cent.,  as  suggested  by 
Van  Arsdale,  is  a  very  satisfactory  application. 

X-ray  Treatment.  The  X-ray  as  a  local  treatment  appears 
to  act  as  a  stimulant  of  the  reparative  processes.  It  is  of  espe- 
cial value  as  an  adjunct  in  the  cases  in  which  the  tissues  about 
the  joint  are  infiltrated  and  traversed  by  discharging  sinuses.  The 
exposure  of  the  diseased  tissues  to  the  direct  rays  of  the  sun  is 
certainly  a  harmless  treatment,  and  it  should  be  applied  if  occa- 
sion offers. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.      259 


ACTIVE  AND  PASSIVE    CONGESTION    IN  THE    TREATMENT 
OF  AFFECTIONS  OF   THE  JOINTS. 

Bier's  treatment  of  tuberculous  joint  disease  was  suggested  by 
the  observation  of  Rokitanski,  that  phthisis  was  uncommon  in 
individuals  suffering  from  disease  of  the  heart  when  the  mechan- 
ical obstruction  was  sufficient  to  cause  venous  congestion  of  the 
lungs. 

Passive  or  venous  congestion  of  a  joint  is  attained  by  con- 
stricting the  limb  with  several  circular  turns  of  a  rubber  bandage 
above  the  affected  joint  sufficiently  to  interfere  with  the  return  of 
the  venous  blood,  but  not  with  the  arterial  supply. 

The  congestion  is  localized  by  bandaging  the  limb  firmly  with 
flannel  or  other  somewhat  elastic  material  up  to  the  lower  margin 
of  the  joint.  When  properly  applied  the  joint  becomes  swollen 
and  dark  red  in  color.  The  local  temperature  is  raised.  This 
is  what  Bier  calls  hot  congestion,  as  distinct  from  oedema  (cold 
congestion)  that  would  result  if  the  rubber  bandage  were  applied 
so  tight  as  to  constrict  the  arteries.  Passive  congestion  should 
not  cause  or  increase  pain.  If  it  has  this  effect  it  is  improperly 
applied  or  is  unsuitable  for  the  case  (Fig.  160). 

The  action  of  the  venous  or  passive  congestion  is,  according 
to  Bier,  as  follows  : 

1.  It  increases  the  formation  of  fibrous  tissue  and  induces 
hypertrophy  of  the  bones. 

2.  It  has  a  bactericidal  action  in  infectious  joint  disease, 
notably  tuberculosis. 

3.  It  exercises  an  absorptive  effect  on  the  effused  products  of 
disease  and  on  new  formations  that  check  joint  motion. 

4.  It  relieves  pain  and  lessens  the  activity  of  progressive  joint 
disease. 

The  most  important  indication  for  passive  congestion  is  in  the 
treatment  of  tuberculous  disease. 

As  applied  for  the  purpose,  when  the  patient  has  become 
accustomed  to  its  use,  it  is  continued  during  the  day  and  discon- 
tinued at  night,  the  limb  being  elevated  to  allow  for  the  escape  of 
the  venous  blood.  If  applied  for  disease  of  the  wrist-joint  it  is 
unnecessary  to  bandage  the  fingers,  as  the  finger-joints  are  usually 
stiff  either  from  disuse  or  from  adhesions  about  the  tendons — a 
condition  for  which  treatment  by  venous  congestion  is  indicated. 

Passive  congestion  for  tuberculous  joint  disease  should  be  sub- 


260 


ORTHOPEDIC  SUBGEBY. 


ordinated  to  protective  treatment,  although  this  is  not  the  opinion 
of  Bier,  who  favors  motion  rather  than  fixation  of  the  diseased 
joint.  It  may  be  continued  indefinitely  according  to  its  effect. 
As  a  rule,  pain  is  lessened  by  the  treatment  and  muscular  spasm 
decreases.  This  latter  effect  is  in  part,  at  least,  explained  by  the 
constriction  of  the  muscles  of  the  thigh. 


Fig.  160. 


Fig.  161. 


The  alcohol  lamp  and  chimney, 
for  active  congestion.    (Bier.] 


Used 


Abscess  formation  or  ap- 
pearance at  least  is  apparently 
favored  by  the  congestion. 
This  may  be  treated  by  aspira- 
tion or  incision,  and  by  the  in- 
jection of  the  iodoform  emul- 
sion if  desirable. 

Passive  congestion  is  em- 
ployed also  for  the  treatment 
of  chronic  disability  following 
injury,  for  chronic  disease, 
such  as  rheumatoid  arthritis  or  other  affection  attended  by 
infiltration  of  the  tissues.  In  this  class  of  cases  the  local  con- 
gestion should  be  reduced  by  active  daily  massage  instead  of  by 
elevation  of  the  limb. 


The  application  of  passive  congestion.  A, 
the  alternate  point  for  the  application  of  the 
bandage,  in  order  to  avoid  atrophy  from  con- 
tinuous pressure.  B,  the  rubber  bandage. 
(Bier.) 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS.      261 

The  treatment  of  acute  infectious  processes  by 'passive  conges- 
tion occupies  a  subordinate  or  experimental  position. 

Active  Congestion.  Active  congestion  is  induced  by  the  local 
use  of  heat,  ordinarily  hot  dry  air. 

In  its  simplest  form  the  apparatus  consists  of  an  alcohol  lamp 
provided  with  a  long  metal  chimney  reaching  to  a  box  of  wood 
or  metal,  into  which  the  limb  is  inserted  through  openings  at 
either  end.  The  box  has  one  or  more  small  openings  for  the 
escape  of  air  and  moisture.  The  limb  is  usually  wrapped  in 
sheet  wadding,  and  is  particularly  well  protected  from  the  parts 
of  the  box  which  may  come  in  contact  with  the  skin.  The  heat 
is  then  applied,  usually  to  about  250°  or  300°  F.,  for  from 
thirty  minutes  to  an  hour  daily.     The  degree  of  heat  is  indicated 

Fig.  162. 


The  application  of  the  hot-air  box  for  inducing  active  congestion.  The  box.  C  the  ther- 
mometer. A,  a  metal  pipe  projecting  from  the  box,  into  which  the  chimney  of  the  lamp  is 
placed.    B,  lamp  chimney.    (After  Bier.) 

by  a  projecting  thermometer,  and  it  is  regulated  by  the  comfort 
of  the  patient  and  by  the  observation  of  its  effects. 

Bier  prefers  simple  boxes  of  wood  of  various  shapes  suitable 
for  the  different  parts  of  the  body,  lined  with  packing  cloth 
soaked  in  a  solution  of  water  glass.  He  considers  these  as  effica- 
cious as  the  complicated  and  expensive  appliances,  and  at  the 
command  of  all  who  desire  to  employ  the  treatment  (Fig.  162). 

The  effect  of  the  heat  is  to  induce  arterial  instead  of  venous 
hyperaemia,  and  to  cause  profuse  local  and  general  perspiration. 
Active  hypersemia  is  not  suitable  for  the  treatment  of  active  or 
progressive  joint  disease.  It  exercises  a  dissolving  and  absorb- 
ing action  on  effused  material  and  on  the  tissues  of  new  forma- 
tion causing  limitation  of  motion  within  a  joint.     It  increases 


262  ORTHOPEDIC  SURGERY. 

local  nutrition  ajid  it  relieves  pain.  It  is  especially  indicated  in 
the  treatment  of  local  disability  after  injury,  chronic  effusions 
into  joints,  rheumatoid  arthritis,  chronic  rheumatism,  and  the 
like. 

As  a  rule,  the  application  of  local  heat  should  be  supplemented 
by  massage.  The  profuse  general  perspiration  that  is  induced 
by  it  is  a  contraindication  in  weak  individuals. 


CHAPTER   VI. 

NON-TUBERCULOUS   DISEASES  OF   THE  JOINTS. 

Syphilitic  Diseases  of  the  Joints. 

In  early  infancy  the  characteristic  syphilitic  disease  of  the 
bones  is  a  form  of  osteochondritis.  Painful,  sensitive  swellings 
appear  at  the  epiphyseal  junctions,  either  as  small,  hard  tumors, 
or  as  general  enlargements,  resembling  those  of  rhachitis  (Fig. 
163).  As  a  rule,  several  epiphyses  are  involved,  more  often 
those  at  the  distal  extremities  of  the  bones  of  the  lower  limbs, 
and  in  these  cases  the  pain  and  discomfort  may  induce  an  appear- 
ance of  helplessness  of  the  part  called  pseudoparalysis  (Parrot). 
In  osteochondritis  there  is  a  multiplication  and  irregularity  of 
the  cartilage  cells  of  the  ossifying  layer  and  premature  calcifica- 
tion. As  a  result,  the  circulation  is  insufficient  and  necrosis  of 
a  part  of  the  cartilage  may  follow,  which,  acting  as  a  foreign 
body,  sets  up  inflammatory  changes  in  the  adjoining  parts.  The 
process  is  shown  by  a  zone  of  hard,  dry,  yellow  substance  in  the 
ossifying  layer,  adjoining  which  is  an  inflammation  of  the  tissues 
of  the  newly  formed  bone  which  is  in  part  replaced  by  granu- 
lation tissue.  If  the  disease  is  progressive,  ulceration  and  sup- 
puration may  follow;  the  cartilage  may  be  destroyed,  and  the 
epiphysis  may  be  separated,  causing  deformity  and  cessation  of 
growth.  The  neighboring  joint  is  usually  involved  in  the  dis- 
ease. In  the  milder  cases  there  is  a  simple  sympathetic  synovitis  ; 
in  the  advanced  class  a  destructive  arthritis.  In  one  case  seen 
recently  the  symptoms  of  pain  on  motion  combined  with  slight 
effusion  into  several  joints  were  present  without  the  epiphyseal 
enlargement.  The  affection  may  be  distinguished  from  rhachitis 
by  the  accompanying  evidences  of  inherited  syphilis,  by  the 
irregularity  of  the  epiphyseal  involvements,  and  by  the  age  of  the 
patient  and  the  absence  of  the  other  symptoms  of  rhachitis. 

In  the  later  raamfedations  of  hereditary  syphilis,  in  which  the 
bones  in  the  neighborhood  of  the  joint  are  involved  in  syphilitic 
osteoperiostitis,  the  joint  may  be  sympathetically  affected  or  the 
disease  may  actually  perforate  the  joint.     In  this  form  of  disease 


264 


ORTHOPEDIC  SURGERY. 


the  synovial  membrane  is  usually  hypertrophied  and  it  may 
interfere  with  the  function  of  the  joint.  The  fluid  is  increased 
in  quantity  and  the  affection  may  resemble  synovial  tuberculosis. 
A  slow,  chronic,  infiltrating  gummatous  form  of  disease  appear- 
ing in  later  childhood  may  simulate  very  closely  the  appearances 
of  so-called  white  swelling.  It  is  more  common  at  the  knee, 
but  other  joints  are  often  affected  as  well. 


Fig.  163. 


Suppurative  syphilitic  epiphysitis  at  lower  ends  of  radius  and  tibia  in  an  infant  aged 
one  month.  The  child  died  shortly  after  the  drawings  were  made,  and  the  epiphyses  were 
found  lying  loose  in  purulent  cavities.    (Tubby.) 

In  the  secondary  stage  of  acquired  syphilis  pain  and  swelling 
of  the  joints,  resembling  rheumatism,  may  be  present,  and  in 
tertiary  syphilis  the  joint  may  be  involved  in  disease  of  the 
neighboring  bones,  or  the  joint  itself  may  be  primarily  implicated. 

In  most  instances  the  joint  affections  of  syphilis  are  explained 
by  the  history  and  by  the  other  signs  of  syphilitic  disease.  Spina 
ventosa  (Fig.  165),  which  is  classed  as  one  of  the  evidences  of 
syphilis,  is  far  more  commonly  of  tuberculous  origin,  as  is  illus- 
trated by  the  statistics  of  Karewski,^  of  157  cases,  in  which  but 
three  were  due  to  syphilis. 

Syphilitic  disease  of    the  joints  is  uncommon    in  orthopedic 

1  Chir.  Krank.  des  Kindesalters. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       265 

clinics  as  compared  with  those  of  tuberculous  origin.  This  is  as 
might  be  expected,  for  not  only  is  tuberculosis  far  more  common 
than  syphilis,  but  a  very  large  proportion,  according  to  Fournier, 
77  per  cent.,  of  the  syphilitic  children  are  stillborn  or  die 
shortly  after  birth.  Even  in  those  that  survive,  disease  of  the 
bones  or  joints  in  the  form  that  could  be  confounded  with  tuber- 
culosis, is  uncommon   as  compared  with  its  other  manifestations. 

Fig.  164. 


Syphilitic  osteoperiostitis  of  the  tibiae  resembling  anterior  bow-leg.    This  is  the  most 
characteristic  manifestation  of  hereditary  syphilis. 

Treatment.  Some  writers  consider  hereditary  syphilis  to  be  a 
very  important  predisposing  cause  of  tuberculous  disease,  and  be- 
lieve that  many  cases  classed  as  tuberculous  are  in  reality  syphilitic, 
even  if  no  hi.story  or  confirmatory  signs  of  syphilis  are  present. 
There  is  no  reliable  evidence  to  support  this  view.  The  possibility 
of  the  .syphilitic  taint,  remote  or  direct,  should  be  borne  in  mind, 
and  in  doubtful  cases  appropriate  remedies  should  be  employed. 

In    general,   the    treatment  of    the    joint  affection  would    be 


266 


ORTHOPEDIC  SURGERY. 


included  in  the  appropriate  treatment  of  the  disease  of  which  it 
is  a  complication.  If  the  joint  is  involved  in  a  destructive 
process  appropriate  apparatus  to  insure  rest  and  protection  is 
indicated.     The  removal  of  irritative  disease  in  the  neighborhood 


Fig.  165. 


Fig.  166. 


Hereditary  syphilitic   disease   of    the   meta- 
carpus and  phalanges. 


Hereditary  syphilitic  disease  of  the 
joints.  In  this  case  the  interior  of  the 
right  knee-joint  was  lined  with  hyper- 
trophied  folds  of  synovial  membrane.  A 
complete  cure  followed  the  administration 
of  appropriate  remedies. 


of  a  joint  is  sometimes  possible  in  older  subjects,  and  in  this  class 
of  cases  an  exploratory  incision  for  inspection  of  the  joint  is  some- 
times advisable  (Fig.  166). 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       267 


Gonorrhoeal  Arthritis. 

Synonym.     Gonorrhceal  rheumatism. 

So-called  gonorrhoeal  rheumatism  is  an  inflammation  of  a  joint 
caused  by  the  presence  of  gonococci.  It  is  said  to  complicate 
from  2  to  5  per  cent,  of  all  the  cases  of  gonorrhoea,  usually  ap- 
pearing in  the  later  stages  of  that  affection,  and  it  is  more  com- 
mon among  those  who  are  in  a  debilitated  condition. 

Distribution.  In  about  40  per  cent,  of  the  cases  it  is  mon- 
articular and  the  knee-joint  is  most  often  involved.  In  375 
cases  collected  by  Finger  the  distribution  was  as  follows  -} 

Knee 136  Shoulder 24 

Ankle 59  Hip 18 

Wrist 43  Jaw 14 

Finger-joints      ....      35  Other  articulations    .       .       .21 

Elbow 25  

375 

Bennecke^  has  tabulated  78  cases  recently  under  treatment. 
The  78  cases  occurred  in  56  patients,  of  whom  18  were  males, 
38  females.     The  distribution  was  as  follows  : 


Knee 

.    31 

Shoulder 

;      4 

Hip 

.      8 

Elbow  . 

.    10 

Ankle 

.      9 

Wrist    . 

.      6 

other  joints  of  foot    . 

.      6 

Fingers 

.      4 

78 


In  46  cases  recorded  by  Markheim^  one  joint  was  involved  in 
13  cases,  two  joints  in  12,  three  joints  or  more  in  18.  The  order 
of  frequency  was  knee,  hip,  shoulder,  wrist,  and  elbow. 

Symptoms.  The  affection  is  usually  of  a  subacute  character. 
The  joint  becomes  swollen  and  there  is  discomfort,  and  particu- 
larly weakness,  and  stiffness  on  use.  If  the  infection  is  more 
severe  there  may  be  local  heat,  pain,  and  infiltration  of  the 
tissues  with  accompanying  muscular  spasm. 

In  all  the  forms  the  infiltration  of  the  subsynovial  tissues  of 
the  capsule  and  of  the  superficial  tissues  is  more  marked  than  the 
actual  effusion  within  the  joint.  The  more  serious  cases  are  char- 
acterized by  a  peculiar  oedematous,  boggy  swelling  of  the  tissues, 
and  the  skin  is  hot,  sensitive,  and  glazed.  There  is  usually 
intense  pain  on  motion  of  the  limb  or  on  jar.  After  the  subsi- 
dence of  the  acute  symptoms  the  thickening  persists,  and  practical 
anchylosis  may  result. 

'  Taylor.    Venereal  Diseases,  p.  263. 

'^  Die  Gon.  Gelenkentztlndung  nach  beob.,  der  Chir.  Univ.  Klin,  in  der  K.  Charity  zu  Ber- 
lin.   Hirschwald,  Berlin,  1899. 
3  Deutsche  Archiv  f.  kiln.  Med.,  1902,  vol.  Ixxii.  p.  186. 


268  ORTHOPEDIC  S  UB GER  Y. 

Gonorrhoeal  arthritis  has  been  divided  into  three  classes  accord- 
ing to  its  symptoms  and  physical  characteristics  :  the  serous,  the 
serofibrinous,  the  purulent. 

The  serous  form,  is,  as  its  name  implies,  a  simple  effusion 
resembling  other  forms  of  subacute  synovitis,  although  it  is  of  a 
more  chronic  character. 

The  serofibrinous  variety  is  the  so-called  plastic  type  of  inflam- 
mation. In  this  form  fibrin  is  deposited  upon  the  cartilage  and 
it  is  afterward  organized  by  the  growth  of  vessels  into  it  from  the 
synovial  membrane,  a  process  which  erodes  the  cartilage  upon 
which  the  granulations  rest.  The  folds  of  the  synovial  membrane 
adhere  to  one  another,  the  capsule  is  thickened,  and  ligaments  and 
tendons  may  be  involved  in  the  adhesive  inflammation.  These 
changes  within  and  without  tlie  joint  may  seriously  impair  its 
function  after  the  cure  of  the  active  disease. 

The  purulent  form  is  uncommon  ;  it  is  similar  in  its  character- 
istics to  suppurative  arthritis  from  other  causes.  It  is  attended 
by  great  local  heat,  pain  and  swelling,  and  by  constitutional 
disturbance. 

In  orthopedic  clinics  gonorrhoeal  arthritis  is  usually  seen  in 
its  later  stages  when  the  acute  symptoms  have  subsided.  In 
these  cases  swelling  and  pain  persist  in  many  instances,  and  in 
the  more  severe  class  motion  is  limited  or  the  limb  may  be  fixed 
in  an  attitude  of  deformity.  An  obstinate,  monarticular,  painful 
swelling  of  a  joint  suggests  gonorrhoea,  and  its  presence  or  absence 
should  always  be  determined,  since  the  effective  treatment  of  the 
primary  cause  is  essential  to  the  cure  of  the  secondary  affection 
of  the  joint.  The  same  statement  is  true  of  painful,  persistent 
affections  of  bursse  and  tendon  sheaths,  and  of  obstinate  forms  of 
weak  foot. 

Treatment.  The  treatment  of  the  early  stage  of  this  form  of 
arthritis  is  rest  and  compression,  together  with  hot  or  cold  applica- 
tions, as  may  seem  to  be  indicated.  Ichthyol  ointment  in  a  propor- 
tion of  about  40  per  cent,  appears  to  relieve  the  pain  and  to  stimu- 
late the  absorption  of  the  effusion.  If  the  symptoms  are  acute  and 
if  there  is  constitutional  disturbance,  the  joint  should  be  aspirated, 
and  if  the  examination  shows  the  effusion  to  be  seropurulent,  it 
should  be  treated  by  incision  and  drainage.  In  the  chronic 
form,  also,  when  the  capsule  is  distended  by  the  serofibrinous 
effusion,  incision  and  removal  of  the  contents  is  indicated. 

In  the  latter  stages  of  disease  of  the  ordinary  subacute  type, 
the  treatment  is  directed  to  the  absorption  of  the  effused  material 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       269 

within  and  without  the  joint,  and  to  the  restoration  of  functional 
activity.  The  use  of  hot  air,  massage,  the  hot  and  cold  douche, 
static  electricity  and  the  like  are  of  service  in  stimulating  the 
circulation.  If  the  limb  has  become  deformed,  and  if  it  is  fixed 
by  adhesions  and  by  contractions,  the  distortion  may  be  corrected 
and  adhesions  may  be  ruptured  by  forcible  manipulation  under 
anaesthesia.  And  it  may  be  stated  that  in  this  class  of  cases 
restoration  of  function  to  a  greater  or  less  degree  is  often  accom- 
plished by  this  means. 

If,  however,  the  limb  is  fixed  in  the  proper  position  it  is  well 
to  postpone  forcible  measures  until  the  effect  of  the  massage  and 
gentle  passive  movements  have  been  observed. 

Functional  use  is  the  most  effective  restorative  treatment  after 
the  acute  symptoms  have  subsided.  This  is  made  possible  by  the 
employment  of  apparatus  which  limits  motion  to  the  degree  the 
joint  permits  without  causing  discomfort. 

Puerperal  Arthritis.  This  is  so  similar  in  its  characteristics 
to  gonorrhoeal  arthritis  that  a  detailed  description  is  unnecessary. 
It  may  be  stated,  however,  that  puerperal  arthritis  is  usually  of 
a  more  severe  type  than  the  preceding  affection. 


Arthritis  Complicating  Infectious  Diseases. 

The  joints  may  be  involved  in  the  course  of  any  infectious 
disease.  A  mild  form  of  arthritis,  often  involving  several  joints, 
is  common  after  diphtheria  or  scarkdina,  and  it  is  occasionally 
observed  as  a  sequel  of  pneumonia.^  This  is  usually  of  a  more 
severe  type  than  the  preceding  forms. 

Arthritis  following  typhoid  fever  is  often  of  a  severe  and 
destructive  type.  Keen^  has  tabulated  84  cases.  In  43  per 
cent,  of  these  the  hip-joint  was  affected  and  in  40  per  cent, 
spontaneous  dislocation  occurred.  In  a  case  treated  recently 
at  the  Hospital  for  Ruptured  and  Crippled  there  had  been  a 
destructive  arthritis  of  one  hip-joint,  spontaneous  displacement  of 
the  femur  on  the  other  side,  and  secondary  contractions  at  the 
knees  and  ankles,  so  that  the  patient  was  bedridden. 

Treatment.  The  treatment  in  all  forms  of  arthritis  compli- 
cating diseases  of  this  class  is  to  place  the  affected  joint  at  rest, 
to  apply  heat  or  cold  as  may  be  indicated  by  the  local  condition, 

'  Herrick.    American  Journal  of  the  Medical  Sciences,  July,  1902. 
2  Surgical  Comijllcations  and  Sequels  to  Typhoid  Fever. 


270  ORTHOPEDIC  SUBGEBY. 

and  to  prevent  the  secondary  distortions  that  lead  to  fixed 
deformities.  The  presence  of  pus  is,  of  course,  an  indication  for 
immediate  incision  and  efficient  drainage ;  thus,  in  all  doubtful 
cases  the  character  of  the  effusion  should  be  ascertained  by 
aspiration. 

Spontaneous  dislocation,  which  is  comparatively  common  when 
the  hip-joint  is  suddenly  distended  with  fluid,  is  not  likely  to 
occur  unless  the  limb  is  flexed  and  adducted.  This  attitude 
should  be  prevented  by  the  use  of  traction  or  support. 

The  after-treatment  has  been  indicated  already. 

Prognosis.  It  is  evident  that  the  immediate  reaction  to  bac- 
terial infection  and  the  final  results  will  vary  with  the  virulence 
of  the  infection,  the  natural  resistance  of  the  individual  and  of 
the  part  involved.  According  to  Poynton  and  Paine^  the  bacteria 
reach  the  synovial  membrane  through  the  capillaries  of  the 
areolar  tissue,  beneath  the  endothelium,  which  if  uninjured  serves 
as  a  barrier  to  protect  the  joint  cavity.  If  the  joint  is  not 
actually  involved  the  restriction  to  motion  will  depend  upon 
thickening  of  the  tissues  of  the  joint  and  upon  disuse  of  the 
muscles.  In  such  cases  the  prognosis  is  good.  If,  however,  the 
interior  of  the  joint  is  invaded  by  a  process  that  causes  adhesions, 
and  partial  destruction  of  the  cartilaginous  surfaces,  anchylosis  is 
likely  to  follow. 

Marsh^  divides  infectious  arthritis  into  four  classes  : 

1.  Simple  infiltration  of  the  subsynovial  tissues  and  slight 
synovitis. 

2.  Effusion  of  fluid  into  the  synovial  sac — synovitis. 

3.  Infiltration  of  the  periarticular  tissues — plastic  inflammation. 

4.  General  destructive  arthritis.  In  the  first  and  second  classes 
complete  recovery  may  be  anticipated.  In  the  third  class  a  vary- 
ing degree  of  functional  disability  is  to  be  expected  In  the  last 
it  is  inevitable. 

Acute  Arthritis  of  Infancy. 

A  form  of  acute  suppurative  arthritis  primarily  within  the 
joint  or  more  often  secondary  to  disease  of  the  neighboring 
epiphysis  is  not  uncommon  in  infancy. 

Etiology.  The  disease  is  usually  caused  by  staphylococci, 
occasionally  by  other  forms  of  infection.     In  the  early  weeks  of 

1  British  Medical  Journal,  November  1,  1902. 

2  Ibid.,  December,  1902. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       271 

life  it  may  follow  infection  at  the  umbilicus  or  other  surface 
lesion.  It  may  be  secondary  to  one  of  the  exanthemata  or  to 
gonorrhoea,  but  in  many  instances  the  origin  is  not  apparent. 
Falls  or  blows  upon  the  part  appear  to  be  predisposing  causes. 

Townsend^  tabulated  73  cases  of  acute  arthritis,  18  of  which 
were  personal  observations.  To  these  I  am  able  to  add  12 
others,  making  a  total  of  85  cases.  In  64  of  these  the  infection 
was  monarticular;  in  21  more  than  one  joint  was  involved.  The 
distribution  was  as  follows  : 

Hip-joint 45    =    53  per  cent. 

Knee-joint 32    =    37       " 

Ottier  joints 8    =    10       " 

The  sex  was  specified  in  61  cases  :  males,  38  ;  females,  23. 
It  is  of  interest  to  note  that  in  all  reported  cases  the  males  out- 
number the  females.  In  285  cases,  including  the  above  and 
others  reported  by  Gonser,  Demme,  Liicke,  Billroth,  Schede,  and 
Miiller,  the  proportion  was  nearly  3  to  1.^ 

Symptoms.  If  the  infection  is  severe  there  is  immediate  local 
heat,  redness,  swelling  and  oedema,  great  pain,  and  correspond- 
ing constitutional  disturbance.  But  in  many  instances  the  local 
and  general  symptoms  are  less  marked,  the  child  is  fretful,  and 
the  evident  discomfort  caused  by  motion  at  the  affected  joint  is 
mistaken  for  result  of  injury  or  rheumatism.  In  this  class  of  cases 
the  patient  is  not,  as  a  rule,  seen  until  several  weeks  after  the 
onset  of  the  affection.  The  joint  is  then  somewhat  infiltrated 
and  enlarged,  motion  is  painful  and  restricted,  and  the  general 
appearances  are  very  similar  to  tuberculous  disease.  There  are 
also,  without  doubt,  even  milder  forms  of  synovial  infection 
from  which  recovery  is  rapid  and  practically  complete.  These 
cases  are  usually  classed  as  monarticular  rheumatism. 

Treatment.  The  treatment  of  the  suppurative  form  is,  of 
course,  free  incision  and  efficient  drainage.  In  all  cases  the  joint 
must  be  fixed,  preferably  by  a  light  wire  splint,  during  the  active 
stage  of  the  disease.  An  apparatus  is  usually  required  to  prevent 
deformity  or  to  support  the  weak  limb  when  the  patient  begins  to 
walk. 

Prognosis.  If  the  arthritis  is  a  primary  disease  within  the 
joint  complete  recovery  may  follow  evacuation  of  the  pu.s,  but, 
as  a  rule,  the  neighboring  epiphyseal  junction  is  diseased,  sup- 
puration is  prolonged,  and  a  part  of  the  epiphysis  is  destroyed 

1  American  Journal  of  the  Medical  Sciences,  January,  1890. 

2  Gonser.    Jahrbuch  f.  Kinderheilk.,  July,  1902. 


272  OR THOPEDIC  S  UE  GEB  Y. 

before  the  disease  comes  to  an  end ;  thus,  subluxation  or  dis- 
placement with  subsequent  deformity  and  loss  of  growth  are  the 
usual  results  of  this  form  of  disease.  At  the  hip-joint,  for 
example,  the  laxity  of  the  ligaments  and  the  upward  displacement 
of  the  femur  that  follow  destruction  of  the  head  of  the  bone 
cause  symptoms  that  in  later  life  are  often  mistaken  for  those  of 
congenital  dislocation. 

In  some  of  the  cases  there  is,  in  addition  to  the  arthritis,  an 
osteomyelitis  of  the  shafts  of  one  or  more  of  the  bones..  These 
cases  are  usually  fatal,  or,  if  the  patient  survives,  there  is  usually 
necrosis  of  the  affected  bones  and  consequently  extreme  deformity. 

In  the  cases  reported  by  Townsend  the  death-rate  was,  in  the 
monarticular  form,  18  per  cent.  ;  in  the  multiple  form,  73  per 
cent. 

In  a  total  of  122  cases  of  all  varieties  tabulated  by  Hoffmann, 
the  death-rate  was  46  per  cent.  In  87  the  affection  was  confined 
to  one  joint ;  in  the  remainder  from  two  to  five  joints  were 
involved.^ 

Acute  Tuberculous  Arthritis.  In  early  infancy  forms  of 
acute  tuberculous  disease,  especially  at  the  knee-joint,  may  simu- 
late closely  infectious  arthritis.  The  joint  may  become  swollen, 
hot,  and  sensitive  to  pressure,  and  the  onset  may  be  sudden  and 
accompanied  by  constitutional  disturbance.  Such  cases  are  more 
often  observed  in  the  children  of  mothers  suffering  from  advanced 
disease  of  the  lun^s. 


Acute  Osteomyelitis. 

Infectious  osteomyelitis  is  most  common  in  early  life,  and  the 
extremities  of  the  bones  in  the  neighborhood  of  the  epiphyseal 
cartilages  are  most  often  involved.  The  symptoms  are  local 
sensitiveness  of  the  bone,  pain,  and  constitutional  disturbance. 
The  neighboring  joint  is  usually  distended  by  a  sympathetic 
synovitis,  and  the  overlying  tissues  are  usually  infiltrated.  The 
treatment  consists  in  immediate  opening  of  the  bone  at  the  sus- 
picious point,  in  order  to  relieve  the  tension  and  to  establish 
drainage.  In  certain  instances  the  joint  itself  may  be  directly 
involved  in  the  disease.  This  may  be  inferred  if  the  symptoms 
do  not  subside  after  the  bone  has  been  opened.  In  doubtful 
cases  the  joint  should  be  aspirated  for  the  purpose  of  bacteriolog- 

1  Medical  Bulletin,  Washington  University,  September,  1902. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       273 

ical  examination,  but  even  if  pathogenic  bacteria  are  found  the 
treatment  by  incision  or  otherwise  must  be  decided  on  the  clinical 
symptoms. 

Fig.  167. 


Deformities  resulting  from  infectious  osteomyelitis. 

Subacute    Osteomyelitis. 

In  older  subjects  localized  infectious  osteomyelitis  in  the  neigh- 
borhood of  a  joint  may  simulate  tuberculous  disease.  The  onset  of 
the  affection  is,  however,  more  abrupt,  the  surrounding  tissues  are 
infiltrated,  and  the  symptoms  are  usually  more  acute  than  in  the 
latter  affection.  In  this  class  of  cases,  of  the  subacute  type,  the 
lesions  are  often  multiple,  and  in  many  instances  the  source  of 
the  original  infection  is  evident.     The  treatment  of  choice  is  the 

18 


274 


ORTHOPEDIC  SURGERY. 


operative  removal  of  the  diseased  area,  which  is  indicated  l^y 
local  sensitiveness,  and  which  in  many  instances  may  be  demon- 
strated by  the  X-ray. 


Fig.  168. 


Loss  of  growth  following  osteomyelitis  of  the  tibia,  necessitating  removal  of  part  of  the  shaft. 


Osteoarthritis  and  Rheumatoid  Arthritis. 
Deformans.     Rheumatic  Gout. 


Arthritis 


Under  these  titles  are  included  a  group  of  chronic  diseases  of 
the  joints  whose  etiology  is  obscure.  At  the  present  time  these 
diseases  are  usually  classed  as  varying  manifestations  of  one 
pathological  process,  and  the  titles  are  usually  considered  as 
synonymous. 

Clinically,  however,  the  characteristic  types  differ  markedly 
from  one  another.  In  one  form  bone  destruction  is  combined 
with  bone  formation,  and  the  final  result  is  an  irregular  solid 
enlargement  of  the  joint,  usually  combined  with  distortion  of  the 
limb. 

It  has  been  suggested  by  Goldthwait  that  the  term  osteo- 
arthritis should  be  applied  to  this  type. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       275 

The  second  form  resembles  somewhat  rheumatism  in  its  course 
and  distribution.  The  disease  is  primarily  of  the  soft  parts  of 
the  joint,  the  bone  is  only  secondarily  and  superficially  involved, 
and  the  final  result  is  limited  motion  or  anchylosis  without 
enlargement  of  the  joint.  This  form  is  sometimes  classed  as 
atrophic  to  distinguish  it  from  the  former  or  hypertrophic  variety 

Fig.  169. 


Osteoarthritis.  The  hypertrophy  of  the  extremities  of  the  bones  of  the  terminal  phalanges 
(Heberden's  nodes)  is  accompanied  by  erosion  of  the  cartilage.  The  second  interphalangeal 
joint  of  the  second  finger  shows  hypertrophy,  combined  with  destruction  and  lateral  dis- 
placement.    (See  Fig.  170.) 

of  arthritis  deformans,  but  the  term  rheumatoid  arthritis  seems 
to  be  preferable,  as  indicating  that  the  two  varieties  of  chronic 
joint  disease  are  distinct. 

Pathology  of  Osteoarthritis.  The  disease  appears  to  begin  in 
the  cartilage,  vvhicli  becomes  fibrillatcd  and  destroyed  in  the  parts 
subjected  to  greatest  pressure,  while  it  is  thickened  and  heaped  up 


276 


ORTHOPEDIC  SURGERY. 


into  irregular  layers  at  the  periphery,  as  if  under  the  influence  of 
pressure  it  had  been  squeezed  out  from  the  interior  of  the  joint 
(Fig.  171).  The  process  is  supposed  to  consist  in  a  multiplication 
of  the  cartilage  cells  which  in  the  free  portion  of  the  cartilage 
escape  into  the  joint,  while  in  those  parts  covered  by  synovial  mem- 
brane they  are  retained.     When  the  cartilage  disappears  the  bone, 


Fig.  170. 


Rheumatoid  arthritis.    Slight  superficial  erosions  of  the  bones  are  to  be  seen  at  several  of 
the  joints.    Contrast  with  osteoarthritis. 

deprived  of  its  natural  protection,  is  worn  away,  and  under  the 
influence  of  pressure  and  friction  it  becomes  increased  in  density 
and  hardness,  "  eburnated."  Meanwhile  the  irregular  projections 
of  cartilage  at  the  periphery  become  in  part  ossified,  and  this, 
together  with  a  formative  periostitis  of  the  adjoining  bone,  causes 
the    irregular    bony  enlargement    characteristic    of    the    disease. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       277 

The  contour  of  the  bones  and  their  mutual  relation  to  one 
another  are  changed.  The  synovial  membrane  becomes  hyper- 
trophied  and  its  villi,  some  of  which  may  contain  cartilaginous 
nodules,  project  into  the  joint  in  shaggy  fringes.  These  may  be 
detached  from  time  to  time  and  may  form  loose  bodies  within  the 
capsule.  The  synovial  fluid  may  be  greatly  increased  in  quantity, 
distending  the  capsule,  or,  communicating  with  bursse,  it  may  form 
cysts,  as  is  sometimes  observed  at  the  knee-joint.  But  more  com- 
monly the  fluid  is  decreased  in  amount.  The  ligaments  are 
weakened  and  destroyed,  and  the  tendons  about  the  joint  become 
adherent  to  their  sheaths  and  to  the  neighboring  tissues.  The 
muscles  atrophy  and  become  contracted  and  structurally  shortened 
in  accommodation  to  the  deformity. 

Etiology  of  Osteoarthritis.  Little  that  is  positive  is  known 
of  the  etiology  of  osteoarthritis.  Two  factors  are  sufficiently 
evident.  These  are  age  and  injury  or  overstrain.  The  wearing 
out  of  the  joint  is  suggested  by  the  appearances,  and,  as  is  well 
known,  similar  changes  in  slight  degree  are  not  uncommonly 
found  in  the  joints  of  laborers  of  middle  age.  So,  also,  similar 
changes  may  follow  injury,  particularly  fracture  at  the  hip-joint. 
Lessened  local  and  general  resistance  are,  of  course,  predisposing 
causes.  In  locomotor  ataxia,  a  disease  accompanied  by  loss  of 
sensation  and  by  diminished  control  of  movement,  the  nutrition 
of  the  joint  is  lowered  and  its  natural  safeguards  against  injury 
and  overwork  are  removed.  Joint  disease  (Charcot's  disease)  of 
the  character  of  osteoarthritis  in  such  instances  is  undoubtedly 
an  indirect  effect  of  disease  of  the  nervous  apparatus,  but  it  by 
no  means  follows  that  such  or  any  disease  of  the  nervous  system 
is  necessary  to  explain  the  lesions  of  the  ordinary  form.  It 
may  be  mentioned  in  this  connection  that  a  form  of  disease  of 
similar  character  is  very  common  among  domestic  animals  in  old 
age.  It  has  been  suggested,  and  it  is  probably  true,  that  defective 
assimilation  may  be  a  causative  factor  in  both  man  and  animals. 

Symptoms.  In  its  typical  form  osteoarthritis  is  an  affection 
of  middle  life  and  of  old  age.  It  may  be  confined  to  a  single 
joint,  and  in  these  cases  one  of  the  larger  joints  of  the  lower 
extremity  is  more  often  affected,  particularly  the  hip  or  knee. 
As  a  rule,  however,  several  joints  are  involved  to  a  greater  or 
less  degree.  Its  onset  is  usually  insidious,  and  the  progress  is 
slow,  accompanied  by  remission  of  the  symptoms. 

These  symptoms  are  usually  pain,  discomfort  in  changing  from 
one  position  to  another,  "  creaking "  sensations  in  the  affected 


278 


ORTHOPEDIC  SURGERY. 


joints,  gradually  increasing  local  enlargement,  limitation  of 
motion,  and  distortion  of  the  limb.  Typical  examples  are  found 
in  the  hip-joint  (malum  coxse  senile)  and  knee,  and  these  are 
described  elsewhere. 

Heberden's  Nodosities.  Although  typical  osteoarthritis  may  be 
confined  to  one  or  more  of  the  larger  articulations,  it  is  often 
accompanied  by  enlargement  of  the  joints  of  the  fingers.  It 
should  be  stated,  also,  that  there  is  a  form  of  osteoarthritis  of 
comparatively  slight  importance  in  which  the  disease  is  confined 

Fig.  171. 


Arthritis  deformans,  from  the  Museum  of  the  College  of  Physicians  and  Surgeons,  New  York. 


to  the  joints  of  the  fingers.  The  bases  of  one  or  more  of  the 
distal  phalanges  become  enlarged  (Heberden's  nodosities),  and 
the  fingers  become  somewhat  stiff  and  painful.  Gradually  other 
phalangeal  joints  become  involved  until  the  fingers  become 
deformed  and  function  is  somewhat  interfered  with.  The  dis- 
ease is  slowly  progressive,  pain  lessening  as  the  enlargement 
and  stiffness  become  more  apparent.  When  the  disease  begins 
in  this  manner  the  larger  joints  are  not  often  implicated.  It 
is  interesting  to  note,  however,  that  this  form  of  disease  is  far 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       279 

more  common  in  women  than  in  men,  and  it  may  be  accompanied 
by  enlargements  of  the  larger  joints  of  the  nature  of  rheumatoid 
arthritis  (Fig.  169). 

Treatment.  In  general,  this  should  be  directed  to  the  im- 
provement, if  possible,  of  the  condition  of  the  patient ;  the  daily 
routine  should  conform  to  what  experience  shows  to  be  that  best 
adapted  to  the  disability.  The  local  nutrition  may  be  maintained 
by  massage,  electricity,  and  the  like.  Deformity  may  be  pre- 
vented and  pain  may  be  relieved  by  regulating  the  strain  to  which 
the  weak  part  is  subjected.  In  certain  instances  operative 
removal  of  villous  proliferations  of  the  synovial  membrane  or  of 
solid  projections  that  interfere  with  movement  may  be  of  service. 
(See  Spondylitis  Deformans  and  Osteoarthritis  of  the  Hip  and 
knee.) 

Rheumatoid  Arthritis. 

Rheumatoid  arthritis  differs  from  the  preceding  type  in  that 
it  is  rather  an  affection  of  childhood  and  of  early  adult  life  than 
of  old  age.  It  is  more  common  among  females  than  males.  It 
is  more  acute  in  its  onset,  more  rapidly  progressive,  and  more 
general  in  its  distribution  than  osteoarthritis. 

In  typical  osteoarthritis  the  cartilage  is  worn  away  at  the 
centre  of  the  joint  and  heaped  up  at  the  periphery.  In  typical 
rheumatoid  arthritis  the  affection  is  primarily  of  the  fibrous  cov- 
erings and  of  the  membranes  of  the  joint,  and  the  cartilage  is 
destroyed  in  the  later  stages  by  a  pannus-like  growth  from  the 
periphery.  There  is  erosion  of  the  cartilage  and  of  the  underlying 
bone  unaccompanied  by  the  hypertrophy  characteristic  of  the  pre- 
ceding disease.  In  rheumatoid  arthritis  a  spindle-shaped  enlarge- 
ment of  the  finger-joints  is  common,  but  the  X-ray  picture  will 
not  show  irregular  bone  formation  as  in  typical  osteoarthritis 
(Heberden's  nodosities),  but  a  normal  contour  of  the  bones  or 
superficial  erosions  entering  into  the  formation  of  the  joint.  The 
second  interphalangeal  joints  are  usually  involved  primarily. 
There  is  usually  flexion,  contraction,  and  in  many  instances  general 
deviation  of  the  fingers  toward  the  ulnar  side.  In  younger 
subjects,  particularly  in  the  class  of  cases  in  which  the  onset  of 
the  disease  is  acute,  and  in  which  there  is  considerable  effusion, 
there  may  be  subluxation  or  actual  luxation  of  the  phalanges, 
more  often  at  the  metacarpal  articulations.  In  such  instances 
motion  is  preserved  in  the  affected  joints. 

In  typical  cases  the  final  result  in  any  joint  is  either  anchylosis 
or  limited  motion   accompanied  by  flexion  deformity.     There  is. 


280 


ORTHOPEDIC  SURGERY. 


of  course,  general  atrophy  of  the  long  bones  in  degree  corre- 
sponding to  the  functional  disability  that  is  present. 

The  onset  of  rheumatoid  arthritis  may  be  acute,  resembling 
rheumatism,  many  joints  being  involved  simultaneously.  It  may 
be  subacute  and  even  limited  primarily  to  a  single  joint. 

The  larger  joints  may  be  involved  before  those  of  the  hands, 
or  vice  versa.  In  childhood  the  disease  often  begins  in  one  of 
the  larger  joints,  causing  stiffness,  deformity,  and  pain  on  motion. 
There  is  usually  some  local  heat  and  infiltration,  increasing  and 
diminishing  according  to  the  strain  or  injury  to  which  the  joint 
may  be  subjected.     In  cases  of  this  character  the  affection  is 


Fig.  172. 


Rheumatoid  arthritis  in  a  child,  showing  the  characteristic  deformity.    Nearly  every  joint 
in  the  body  is  Involved. 

usually  mistaken  for  tuberculous  disease,  until  the  involvement 
of  other  joints  indicates  the  true  character  of  the  affection.  As 
a  rule,  the  affection  is  progressive  in  character,  both  locally  and 
generally.  The  range  of  motion  in  the  affected  joint  becomes 
more  and  more  restricted,  the  limb  becomes  flexed,  and,  finally, 
there  is  practical  anchylosis,  usually  due  to  adhesions  and  con- 
tractions within  and  without  the  joint.  In  those  cases  in  which 
the  cartilage  is  in  part  destroyed  by  the  growth  of  granulation 
tissue  from  the  periphery  there  may  be  actual  bony  union.  In 
many  instances  the  spine  becomes  rigid,  including  the  occipito- 
axoid  articulations,  and  practically  every  joint  of  the  body  may  be 
finally  involved,  so  that  the  patient  is  bedridden  and  helpless. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       281 

The  disease  is  more  serious  and  more  rapidly  progressive  in 
the  young  than  in  older  subjects.     There  are  periods  of  remission 

Fig.  173. 


Still's  form  ot  polyarthritis,  showing  the  general  atrophy,  the  enlarged  joints,  and  the 
prominence  of  the  stomach,  due  to  amyloid  degeneration  of  the  liver  and  spleen. 

and  of  exacerbation.  In  some  instances  the  disease  appears  to 
come  definitely  to  an  end,  leaving  the  stiffened  joints,  and  occa- 
sionally complete  recovery  takes  place,  but  this  is  unusual. 

Fig.  174. 


The  hands  in  the  case  shown  in  the  preceding  figure. 

A  peculiar  form  of  the  affection,  first  described  by  Still/ 
occurs  in  childhood.  This  begins  usually  in  one  or  more  of  the 
larger  joints.      As  a  rule,  it  progresses  rapidly,  and  it  is  accom- 


1  Medico-Chir.  Transactions,  1897. 


282  ORTHOPEDIC  SURGERY. 

panied  by  enlargement  of  the  lymphatic  glands  particularly  those 
of  the  inguinal  region  and  axilla,  and  of  the  liver  and  spleen. 
There  is,  as  a  rule,  moderate  effusion  into  the  joints  and  thicken- 
ing of  the  overlying  tissues.  As  the  muscular  atrophy  is  extreme, 
the  joints  appear  by  contrast  very  much  enlarged.  The  final 
outcome  of  the  disease  is  anchylosis  and  deformity,  as  in  the 
ordinary  form.     Occasionally  complete  recovery  occurs. 

Etiology.  Of  the  etiology  of  rheumatoid  arthritis  little  is 
known.  Certain  aspects  of  the  disease  resemble  closely  those 
caused  by  infection  from  without.  This  is  particularly  noticeable 
in  those  cases  in  which  the  disease  begins  in  one  or  more  of 
the  larger  joints.  On  the  other  hand,  infectious  joint  disease  is 
not  slowly  progressive,  as  is  rheumatoid  arthritis  in  its  typical 
form.  It  is  probable,  however,  that  certain  forms  of  infectious 
arthritis  of  a  mild  character  are  included  in  what  is  now  known 
as  rheumatoid  arthritis.  Auto-infection,  due  to  defective  assimi- 
lation, is  probably  a  predisposing  and  exciting  cause,  as  it  is  well 
known  that  this  aggravates  the  symptoms  of  the  disease  when  it 
is  once  established. 

Other  causes  are  apparently  lack  of  vital  resistance  due,  it 
may  be,  to  overwork  or  strain,  mental  or  physical,  and  exposure 
to  cold  or  wet.  It  may  be  stated,  also,  that  some  obscure  affection 
of  the  nervous  system  has  been  assigned  by  certain  writers  as  a 
probable  cause. 

Treatment.  In  general,  this  must  be  directed  to  improving 
the  condition  of  the  patient  by  the  regulation  of  the  diet,  which 
must  be  nourishing  and  easily  assimilated.  Exposure  to  cold 
and  wet  and  overexertion  must  be  avoided.  The  use  of  static 
electricity,  the  hot-air  and  the  electric-light  baths,  as  general  and 
local  stimulants  are  of  service.  Ichthyol  ointment,  the  cautery, 
and  the  like  may  be  employed  locally.  If  the  joints  are  sensitive 
motion  should  be  restricted  to  the  painless  area  by  apparatus. 
Passive  motion  or  massage  that  increases  the  pain  or  discomfort  is 
harmful,  but  motion  should  be  encouraged  when  the  disease  is 
quiescent.  Contraction  deformity  may  be  overcome  by  forcible 
manipulation,  and,  if  necessary,  by  tenotomy  when  the  disease  is 
quiescent.  Excision  of  an  anchylosed  joint,  as  of  the  lower  jaw 
or  elbow,  may  re-establish  painless  motion. 

It  may  be  noted  as  of  interest  that  what  appears  to  be  typical 
rheumatoid  arthritis  in  childhood  may  be  induced  apparently  by 

1  Whitmau.    Medical  Record,  April  18, 1903. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       283 

infectious  disease,  such  as  diphtheria  for  example,  and  that 
improvement,  or  even  disappearance  of  the  local  symptoms  may 
follow  intercurrent  attacks  of  scarlatina  or  measles.  It  is  possi- 
ble, therefore,  that  serum-therapy  may  be  employed  in  the  future. 
Although,  as  has  been  indicated,  typical  cases  of  rheumatoid 
arthritis  differ  so  essentially  from  osteoarthritis  as  to  be  classed 
as  distinct  diseases,  yet  there  are  types  that  it  is  difficult  to  classify 
as  the  one  or  the  other,  and  in  certain  instances  the  two  forms 
may  be  combined  in  one  individual. 

Haemophilia — Hemarthrosis . 

Hemorrhage  into  a  joint  may  occur  in  a  so-called  "  bleeder." 
In  this  class,  which  is  pratically  limited  to  the  male  sex,  the  knee- 
joint  is  most  often  involved.  As  a  rule,  it  is  the  result  of  injury, 
and  if  the  peculiarity  of  the  patient  is  known  the  nature  of  the 
effusion — hemorrhagic — is  hardly  doubtful,  particularly  as  there 
is  in  many  instances  discoloration  of  the  skin,  either  over  the  joint 
or  elsewhere.  In  some  instances  there  is  no  history  of  traumatism, 
and  the  swelling  may  be  accompanied  by  fever.  This  is  probably 
the  effect  of  the  hemorrhage  rather  than  its  cause. 

The  peculiar  interest  in  the  affection,  aside  from  the  importance 
of  a  proper  diagnosis,  lies  in  the  fact  that  the  further  organiza- 
tion of  the  effused  blood  may  cause  symptoms  and  changes  about 
the  joint  that  may  be  mistaken  for  those  of  tuberculous  disease. 
There  may  be,  for  example,  persistent  swelling,  thickening  of  the 
tissues,  limitation  of  motion,  and  deformity  combined  with  more 
or  less  weakness  and  discomfort.  These  symptoms  are  explained 
by  the  irritation  of  the  effused  blood  and  by  its  further  absorp- 
tion and  organization,  which  necessitates  the  formation  and  growth 
of  new  bloodvessels ;  practically,  a  granulation  tissue  is  formed 
that  may  erode  the  cartilage  upon  which  the  fibrinous  deposits 
rest.  These  secondary  changes  resemble  the  early  stage  of 
osteoarthritis. 

Treatment.  The  local  treatment  is  rest  and  protection  com- 
bined with  stimulating  applications  to  hasten  the  absorption  of 
the  effused  blood.  Several  deaths  have  been  reported  from  hemor- 
rhage after  operative  intervention  in  cases  in  which  the  affection 
had  been  mistaken  for  tuberculous  disease. 

Hemarthrosis. 

Hemorrhage  into  a  joint  may  occur  in  normal  individuals,  and 
its  presence  is  not  always  indicated  by  superficial  discoloration. 


284 


OB  THOPEDIC  S  UB  GEB  Y. 


The  swelling  is  more  resistant  than  is  the  ordinary  effusion,  and 
it  is  far  more  persistent.  This  suggests  the  advisability  of  in- 
cision and  removal  of  the  blood  clots  in  certain  instances  in  order 
to  relieve  the  joint  of  burden  of  their  organization  and  absorption. 

Scorbutus — Scurvy. 

This  affection  is  sometimes  attended  with  hemorrhage  into  and 
about  the  joints.  It  will  be  considered  in  connection  with  in- 
fantile rhachitis. 

Charcot's  Disease. 

Charcot's  disease  is  a  form  of  destructive  arthritis  which  is 
secondary  to  locomotor  ataxia. 

Pathology.  It  resembles  somewhat  in  its  pathology  osteo- 
arthritis.     The   cartilage    degenerates,   and,  together    with   the 

Fig.  175. 


Charcot's  disease  of  the  knee-joiat. 


underlying  bone,  is  worn  away  by  the  movements  of  the  limb. 
Accompanying  the  destructive  process  there  is  an  exaggerated 
and  irregular  formation  of  cartilage  and  bone  about  the  periphery 
of  the  joint.     The  synovial  membrane  is  hypertrophied,  and  may 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       285 

be  covered  in  places  with  calcareous  plates  ;  the  contents  of  the 
joint  is  usually  increased  in  quantity. 

The  joint  disease  usually  appears  early  in  the  course  of  loco- 
motor ataxia,  often  before  its  existence  is  suspected,  and  it  is 
sometimes  caused  by  injury. 

Charcot's  disease  is  said  to  affect  about  5  per  cent,  of  the  ataxic 
patients ;  it  is  more  common  in  the  lower  extremity,  and  one  or 
more  joints  may  be  involved.  In  the  cases  tabulated  by  Flatow 
the  distribution  was  as  follows  : 

Knee 60 ;  in  13  cases  both  knees. 

Foot 30;    "     9     "        "    feet. 

Hip 38;    "     9     "         "    hips. 

Shoulder 27 ;    "     6     "        "    shoulders. i 

Chipault^  notes  the  distribution  in  2 1 7  cases,  as  follows  : 

Knee 120 

Hip 57 

Foot 40 

Fifteen  cases  of  Charcot's  disease  involving  the  spine  have 
been  reported.' 

Symptoms.  The  symptoms  are  the  swelling  due  to  the  effu- 
sion, laxity  of  the  ligaments,  and  deformity.  There  is  but  little 
pain,  and  the  patient's  chief  complaint  is  of  the  weakness  and 
distortion  of  the  limb.  In  certain  cases  the  progress  of  the  affec- 
tion is  very  rapid,  and  the  destruction  of  bone  may  be  so  exten- 
sive that  there  is  an  actual  luxation  at  the  affected  joint. 

Diagnosis.  If  the  patient  is  known  to  have  locomotor  ataxia 
the  diagnosis  will  be  evident,  and  in  any  event  the  peculiar 
enlargement,  and  thickening  of  the  tissues,  together  with  the 
excessive  laxity  of  the  ligaments,  characteristic  of  this  affection, 
which  has  been  called  a  caricature  of  osteoarthritis,  should  call 
attention  to  the  disease  of  the  spinal  cord. 

Treatment.  The  treatment  of  the  local  disease  is  efficient 
support  to  prevent  progressive  distortion.  Excision  of  the  knee 
has  been  performed,  but  in  many  cases  the  bones  have  failed  to 
unite,  and  on  this  account  the  operation  is  contraindicated. 

Disease  of  joints  secondary  to  other  forms  of  disease  of  the 
nervous  system  may  occur.  It  is  most  common  as  a  complication 
of  syringomyelia,  in  which,  in  contrast  to  locomotor  ataxia,  the 
joints  of  the  upper  extremity  are  far  more  often  involved  than 
of  the  lower. 

'  Deutsche  Chir.,  1900,  vol.  1.  p.  28,  s  Le  Dentu  et  Delbet,  Traits  de  Chir. 

'■  Abadie.    Nouv.  Icon,  de  la  SalpOtrii^re,  T.  xiii.,  1900.    Cornell,  Johns  Hopkins  Hosp.  Bull., 
October,  1902. 


286  OB THOPEDIC  S  UB GEB  Y. 

In  Schlesiuger's  cases  the  distribution  was  as  follows  -} 

Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot 7 

Other  joints 8 

97 

In  all  forms  of  joint  disease  secondary  to  disease  of  the  nervous 
system  the  influence  of  injury  on  the  ill-nourished  or  ill-protected 
part  is  recognized  in  the  causation  and  in  the  progress  of  the 
disease. 

This  indicates  the  principles  of  local  treatment. 

Anchylosis. 

Anchylosis  implies  fixation  in  an  attitude  of  deformity,  and 
the  term  should  be  restricted  to  practical  fixation  caused  by  tissue 
changes  within  or  without  a  joint,  but  it  is  often  incorrectly 
applied  to  limitation  of  motion,  such  as  may  be  caused,  for 
example,  by  muscular  spasm. 

Etiology  and  Pathology.  Anchylosis  may  be  the  result  of 
actual  union  of  two  bones  whose  cartilages  have  been  destroyed, 
a  synostosis.  This  is  sometimes  called  true,  as  distinguished 
from  false  or  fibrous  anchylosis. 

It  may  be  caused  by  adhesions  between  the  folds  of  synovial 
membrane,  by  adhesions  and  contractions  of  the  capsular  and 
other  ligaments,  by  adhesions  between  the  tendons  and  their 
sheaths,  by  the  general  adhesions  and  contractions  caused  by 
burrowing  abscesses,  and  by  the  retraction  and  structural  shorten- 
ing of  muscles  when  the  deformity  has  persisted  for  a  sufficient 
time.  It  may  be  caused,  also,  by  fractures  or  dislocations  or  by 
marginal  exostoses. 

Anchylosis  is  usually  secondary  to  an  inflammatory  affection 
of  the  joint  during  which  the  adhesions  have  formed  within  and 
without  the  capsule,  and  if  deformity  has  been  allowed  to  persist 
the  muscles  are  atrophied  and  structurally  shortened  on  the  con- 
tracted side. 

Prevention  and  Treatment.  The  danger  of  anchylosis  may 
be  lessened  by  the  proper  treatment  of  the  disease  of  which  it 
is  a  result.  In  tuberculous  disease,  for  example,  motion  may  be 
preserved  in  many  instances  by  efficient  protection,  by  which  the 

1  Die  Syringomyelie,  Wien,  1895. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       287 

area  of  the  disease  is  restricted  and  its  destructive  effects  checked. 
In  this  class  of  cases  the  joint  should  be  fixed  during  the  pro- 
gressive stage  of  the  disease,  in  the  attitude  in  which  anchylosis, 
if  it  be  unavoidable,  will  least  inconvenience  the  patient,  and,  if 
possible,  efficient  traction  should  be  employed  with  the  aim  of 
separating  the  surfaces  of  the  adjoining  bones. 

Fig.  176. 


A  useful  form  of  brace  for  weak  knee,  in  which  the  range  of  motion  is  regulated  by  means 
of  an  adjustable  wheel.    (Shaffer.) 

Formerly  it  was  believed  that  prolonged  fixation  of  a  diseased 
joint  would  of  itself  induce  anchylosis,  but  now  that  it  is  known 
that  final  limitation  of  motion  is  dependent  upon  the  severity  and 
the  duration  of  the  disease,  prolonged  rest  is  believed  to  be  the 
most  efficient  means  of  assuring  motion. 

In  tuberculous  cases,  when  the  disease  is  cured,  functional  use 
will  ordinarily  restore  all  the  motion  of  which  the  part  is  capable. 


288 


ORTHOPEDIC  SURGERY. 


Fig.  177. 


In  other  inflammatory  affections  of  the  joint  which  are  usually  of 
infectious  origin  the  violence  of  the  initial  process  may  be 
restrained  by  the  local  application  of  cold  or  heat,  or  by  the 
removal  of  the  contents  of  the  joint  if  the  infection  is  severe. 

In  all  cases  the  joint  should  be 
properly  supported  in  order  to 
relieve  pain  and  to  prevent  de- 
formity. 

Passive  Motion.  When  the 
acute  symptoms  have  subsided 
the  absorption  of  the  plastic  ma- 
terial may  be  hastened  by  mass- 
age, the  hot-air  bath,  and  the  like, 
and  by  carefully  regulated  passive 
and  active  motion.  Passive  con- 
gestion after  the  method  of  Bier 
may  be  of  service  in  certain  cases. 
It  is  highly  recommended  by 
Blecher.^  In  the  final  stage,  when 
there  is  no  longer  evidence  of  ac- 
tive disease,  passive  movements 
under  anaesthesia  may  be  of  ser- 
vice in  breaking  adhesions,  espe- 
cially if  these  are  without  the 
joint.  Passive  movements  that 
cause  persistent  discomfort  or 
pain,  which  are  often  employed  in 
the  treatment  of  stiff  joints,  even 
when  the  disease  is  active,  are 
absolutely  contraindicated.  If, 
however,  the  limb  during  the 
course  of  the  disease  has  become 
deformed,  it  should  be  restored 
to  its  proper  position  as  soon  as 
possible,  even  though  force  is  re- 
quired. This  treatment  is  indi- 
cated in  order  to  prevent  secondary  retraction  of  the  muscles  and 
fasciae. 

Forcible  Correction.     The  class  of  cases  in  which  the  limb  has 
become  fixed  in  deformity  is  the  most  favorable  one  in  which 


Anchylosis  at  the  hip,  showing  masses  of 
new  bone.  (From  the  Museum  of  the  Col- 
lege of  Physicians  and  Surgeons.) 


1  Deutsche  Zeits.  f.  Chir.,  Bd.  Ix.  p.  250. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS.       289 

to  perform  the  so-called  brisement  forc§,  because  the  rectification 
of  deformity  is  always  indicated,  and  in  accomplishing  this  there  is 
always  the  prospect  of  regaining  a  certain  degree  of  motion.  If, 
however,  there  is  no  deformity  the  advisability  of  forced  movement 
will  depend  on  the  character  of  the  preceding  disease  as  well  as 
upon  the  condition  of  the  joint.  It  is  rarely  advisable  to  disturb 
a  tuberculous  joint,  or  at  least  not  until  long  after  the  cure  of  the 
disease ;  but  if  the  anchylosis  has  followed  infectious  arthritis  of 
a  mild  form,  or  monarticular  "  rheumatism,"  forcible  manipula- 
tion may  be  attempted.  If  under  gentle  manipulation  the  adhe- 
sions give  way  suddenly,  allowing  free  motion,  the  prognosis  is 
good ;  but  if  there  be  a  peculiar,  elastic,  continuous  resistance,  as 
when  there  are  extensive  adhesions  within  the  joint,  there  is  little 
likelihood  of  attaining  motion  by  this  means.  If  but  slight  force 
has  been  exerted  there  is  usually  but  little  reaction,  and  massage 
and  passive  motion  may  be  employed  at  once ;  but  in  other 
instances  the  manipulation  is  followed  by  swelling  and  pain, 
and  until  these  symptoms  have  subsided  fixation  may  be  indi- 
cated. 

Afterward,  passive  movements  within  the  range  that  is  practi- 
cally painless  may  be  carried  out  manually,  or  by  means  of  one  of 
the  so-called  pendulum  machines,  by  which  the  joint  is  moved  back 
and  forth  at  frequent  intervals  until  the  part  is  fatigued.  Func- 
tional use,  when  the  joint  is  protected  by  apparatus  that  limits  the 
range  of  motion  to  the  painless  area,  is  also  of  service. 

The  X-ray  may  be  of  value  in  demonstrating  the  condition  of  the 
joint  and  the  degree  of  atrophy  of  the  bones,  but  the  history,  which 
may  indicate  the  character  of  the  disease,  and  the  physical  exami- 
nation are  far  more  reliable  from  the  standpoint  of  prognosis.  In 
some  instances  operative  exploration  of  the  joint  may  be  indicated. 
This  permits  the  removal  of  exostoses  or  displaced  fragments  of 
bone  after  fracture  that  may  limit  motion  mechanically.  Recently 
the  attempt  has  been  made  to  prevent  reunion  of  the  surfaces  of 
the  adjoining  bones  by  the  insertion  of  thin  j)lates  of  magne- 
sium or  other  absorbable  substance,  as  one  prevents  union  in 
smaller  joints  by  interposing  muscular  or  other  tissue  in  a  similar 
manner.     As  yet  the  method  is  in  the  experimental  stage. 

True  bony  anchylosis  in  the  lower  extremity  admits  of  no 
remedy  as  far  as  the  restoration  of  joint  function  is  concerned, 
although  the  symmetry  of  the  limb,  if  it  be  deformed,  may  be 
restored  by  osteotomy. 

In  the  upper  extremity  motion   may  be  restored   by  excision 

19 


290  ORTHOPEDIC  SURGERY. 

of  the  joint,  and  in  some  instances  this  is  advisable,  particularly 
for  anchylosis  at  the  elbow. 

It  may  be  mentioned  that  anchylosis  following  disease  is 
usually  accompanied  by  marked  atrophy  of  the  bones,  and  frac- 
ture may  occur  during  forcible  correction.  In  cases  of  this  char- 
acter the  rare  complication  of  fat  embolism  is  sometimes 
encountered. 


CHAPTEE   YII. 

TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 

Synonyms.     Hip  disease,  morbus  coxse. 

Hip  disease  is  a  chronic  destructive  disease  that  results  in  loss 
of  function  and  deformity.  At  one  time  a  number  of  patholog- 
ical processes  and  even  simple  deformity  (coxa  vara)  were  in- 
cluded under  the  title,  but  it  is  now  limited  to  tuberculous  disease. 

Pathology.  Tuberculous  disease  of  the  hip-joint  usually 
begins  in  several  minute  foci  in  the  neighborhood  of   the  epi- 


FlG.  178. 


Section  of  the  hip-joint  at  the  age  of  eight  years,  showing  the  epiphyses  and  the  relation  ot 
the  capsule.  (Schuchardt.)  At  birth  the  entire  upper  extremity  of  the  femur  is  cartilagi- 
nous. According  to  Jacinsky,  ossification  begins  in  the  head  of  the  femur  at  about  the  tenth 
month;  in  the  trochanter  major  at  from  the  fourth  to  the  eighth  year;  in  the  trochanter 
minor  at  the  eleventh  year.  Ossification  is  complete  at  all  points  at  about  the  eighteenth 
year. 

physeal  cartilage  of  the  head  of  the  femur.  Here  the  circulation 
is  most  active,  and  here  the  newly-formed  bone  is  least  resistant. 
Thus  the  bacilli,  carried  by  the  blood,  are  more  often  deposited 
at  this  point,  wliere,  under  favoring  conditions,  induced  it  may 
be  by  slight  traumatisms,  the  disease  is  established.  These  foci 
coalesce  and  an  area  of  infected  granulations  replaces  the  normal 


292 


OB  THOPEDIC  S  UB  GEB  Y. 


structure.  If  the  local  resistance  is  sufficient  the  disease  may 
be  confined  to  the  interior  of  the  bone,  but  in  most  instances  it 
gradually  forces  its  way  into  the  joint,  and  the  granulation  tissue, 
spreading  under  and  over  the  cartilage,  destroys  it  in  its  progress. 
The  lining  membrane  of  the  joint  becomes  involved  in  the  dis- 
ease, and,  fiually,  the  adjoining  surface  of  the  acetabulum  as  well. 
In   a  certain   indeterminate   number    of    cases    the  tuberculous 

process  begins  about  the  epi- 
'^'     ■  physeal  junctions  of  the  ace- 

tabulum, and  primary  disease 
of  the  synovial  membrane  may 
occur,  although  this  is  cer- 
tainly uncommon  in  child- 
hood. 

From  the  clinical  stand- 
point, primary  disease  of  the 
acetabulum  may  be  inferred 
when  the  patient  is  particu- 
larly susceptible  to  movements 
of  the  trunk,  or  when  lateral 
pressure  on  the  pelvis  causes 
pain ;  or  when  a  Roentgen 
picture  shows  greater  erosion 
of  the  acetabulum  than  of  the 
head  of  the  femur  (Fig.  192). 
There  are  other  cases,  in 
which  the  symptoms  of  the 
disease  are  slight  and  in  which 
the  swelling  of  the  joint  is 
well  marked  ;  in  such  cases  it 
is  probable  that  disease  of  the 
synovial  membrane  is  pres- 
ent, without  marked  involve- 
ment of  the  head  of  the  femur  or  of  the  acetabulum. 

In  the  common  or  osteal  form  of  disease,  while  the  tuber- 
culous process  is  still  confined  within  the  head  of  the  femur, 
the  joint  shows  evidences  of  sympathetic  irritation  ;  the  synovial 
membrane  is  congested,  and  the  fluid  within  the  joint  is  increased 
in  quantity.  These  changes  become  more  marked  as  the  disease 
progresses,  the  lining  membrane  becomes  thickened  and  granular, 
and  adhesions  between  its  folds  lessen  the  capacity  of  the  joint.  An 
amount  of  tuberculous  fluid,  large  enough  to  be  recognized  as  an 


'  Wandering  of  the  acetabulum ' 
(Krause.) 


in  hip  disease. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT. 


293 


"  abscess/'  is  present  in  about  half  the  cases  at  some  time  dur- 
ing the  course  of  the  disease.  This  fluid  usually  finds  an  exit 
from  the  capsule  into  the  tissues  of  the  thigh,  but  occasionally 
it  may  pass  through  the  acetabulum  into  the  pelvis.  In  rare 
instances  the  disease  may  not  enter  the  joint,  but  may  find  an 
opening  in  the  neck  outside  the  capsule.  In  such  cases  the  joint 
is,  in  most  instances,  finally  involved  unless  the  disease  is  removed 
by  surgical  means.  There  are  cases,  also,  in  which  the  disease, 
confined  within  the  head  of  the  bone,  so  weakens  it  that  it 
becomes  distorted  to  a  marked  degree. 

Fig.  180. 


Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of  the  acetabulum.    Formation 
of  new  bone  (osteophytes)  about  the  acetabulum. 

If  the  disease  involves  the  neck  of  the  bone  it  may  sink  down- 
ward, a  form  of  coxa  vara ;  or  the  head  of  the  bone  may  be 
separated  at  the  epiphyseal  junction,  with  consequent  upward 
displacement  of  the  shaft. 

In  by  far  the  larger  number  of  cases  the  joint  is  perforated 
and  the  head  of  the  femur  and  the  acetabulum  are  eroded  to  a 
greater  or  less  degree.  In  such  instances  the  destructive  effects 
of  the  disease  are  increased  by  the  pressure  and  friction  of  the 


294 


OB  THOPEDIC  S  UR  GER  Y. 


softened  bones  on  one  another,  aggravated  by  the  spasm  o£  the 
surrounding  muscles.  Thus  at  the  upper  margin  of  the  acetab- 
ukim  and  the  inner  and  upper  surface  of  the  femur  there  is 
greater  loss  of  substance  than  elsewhere  (Fig.  180). 

The  appearances  in  advanced  cases  of  this  type,  as  seen  at 
operation  or  autopsy,  may  be  summarized  somewhat  as  follows  : 
The  head  of  the  femur  is  deeply  eroded,  its  cartilaginous  cover- 
ing has  practically  disappeared,  or  is  in  part  still  adherent  in 
necrotic  shreds.  It  lies  in  seropurulent  fluid,  embedded  in  the 
gelatinous  necrotic  granulations  that  line  the  capsule  and  partly 
fill  the  enlarged  acetabulum. 


Fig.  181. 


Erosion  of  the  head  of  the  femur  and  of  the  upper  margin  of  the  acetabulum.    A,  anterior 
superior  spine.    B,  anterior  inferior  spine. 


In  certain  instances  the  disease  may  extend  over  the  adjoining 
surface  of  the  pelvis,  or  the  acetabulum  may  be  perforated  (Fig. 
182),  or  the  medullary  cavity  of  the  femur  may  be  implicated. 
Occasionally  the  disease-  may  be  from  the  first  of  an  acute 
destructive  type,  whose  course  is  but  little  influenced  by  treat- 
ment, but  in  the  majority  of  cases  the  progress  of  the  disease 
and  its  destructive  effects  may  be  greatly  modified  by  efficient 
protection  of  the  joint. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  295 

In  the  natural  cure  of  the  disease  the  focus  within  the  bone,  if 
it  be  small,  may  be  absorbed  and  replaced  by  scar-like  tissue ;  or 
the  products  of  the  disease  may  be  separated  from  the  healthy 
parts,  and  discharged  by  abscess  formation.  In  other  instances 
a  part  in  which  the  disease  is  still  active  may  be  enclosed  within 
the  newly-formed  tissue.  Here  the  process  may  remain  quiescent 
or  it  may  cause  relapse,  many  years  after  the  apparent  cure. 
Or  portions  of  necrosed  bone,  enclosed  within  the  capsule,  may 
prolong  suppuration  after  the  tuberculous  disease  has  ceased  to 
progress. 

Etiology.  The  etiology  of  tuberculous  disease  is  discussed  in 
Chapter  V. 

Relative  Frequency.  Tuberculous  disease  of  the  hip-joint  is  the 
most  common  and  the  most  important  of  the  affections  of  the 
joints,  ranking  second  to  Pott's  disease.  In  a  total  of  7845 
cases  of  tuberculous  disease  treated  in  the  out-patient  department 
of  the  Hospital  for  Ruptured  and  Crippled  during  a  period  of 
fifteen  years— 1885-1899— 3203  were  Pott's  disease,  2230  were 
hip  disease,  while  the  remaining  2408  cases  included  all  the 
other  joints. 

Age.  Hip  disease  is  essentially  a  disease  of  early  childhood, 
although  no  age  is  exempt.  In  a  series  of  1000  consecutive 
cases  of  hip  disease  tabulated  for  me  by  Dr.  D.  D.  Ashley,  formerly 
an  assistant  in  the  department,  88.1  per  cent,  of  the  patients  were 
in  the  first  decade  of  life,  and  45.6  per  cent,  of  these  were  from 
three  to  five  years  of  age,  inclusive. 


Age  at  Incipiency. 


Less  than  1  year 

.      9 

Between  16  and  17  years 

11 

Between  1  and  2  years 

.     89 

17    "    18      " 

4 

2    "      3      " 

.  107 

18    "    19      " 

5 

3    "      4      " 

.  155 

19     "     20      " 

0 

4     "      5      " 

.  158 

20    "     21      " 

3 

5     "      6      " 

.  139 

21     "     22      " 

3 

6     "      7      " 

.     90 

22    "    23      " 

1 

7     "      8      " 

.     51 

"        23    "    24      " 

2 

8    "      9      " 

.     51 

"        24     "    25      " 

3 

9     "     10      " 

.     40 

25    "    26      " 

10     "     11      " 

.    33 

26     "     27      " 

11     "    12      '• 

.     19 

27     "    28      " 

12     "     13      " 

.     18 

28     "    29      " 

13     "     14      " 

.     23 

30    "    33      " 

14     "     15      " 

.      7 

33     "    36      " 

15    "     16      " 

.      8 

Age  not  Stated 

1000 


Sex.     Sex    exercises    but    little    influence    in    predisposition, 
altljoiigh    the    disease    is    slightly  more  common  among    males 


296 


ORTHOPEDIC  SURGERY. 


than  among  females.  In  the  1000  cases  referred  to,  553  (55.3 
per  cent.)  were  in  males,  447  were  in  females. 

In  3307  cases  treated  at  the  same  institution,  53  per  cent, 
were  in  males. 

Side  Affected.  In  disease  of  this  as  of  other  joints  the  right  is 
somewhat  more  often  affected  than  the  left.  In  the  1000  cases 
506  were  on  the  right  side,  483  were  on  the  left,  and  in  11  cases 
both  joints  were  involved.  In  a  larger  number  of  cases  treated 
in  the  department  53  per  cent,  were  of  the  right  joint. 

Symptoms.  Tuberculous  disease  of  the  hip-joint  is  a  chronic, 
insidious  affection  characterized  by  occasional  exacerbations  of 

Fig.  182. 


Erosion  of  the  head  of  the  femur  and  destruction  of  the  acetabulum. 


more  acute  symptoms  that  are  induced  by  overstrain  or  injury, 
by  a  more  rapid  advance  of  the  destructive  process,  or  by  infec- 
tion with  pyogenic  germs.  In  the  early  stage  of  the  disease  the 
joint  is  simply  sensitive,  and  the  symptoms  vary  with  the  activity 
of  the  disease,  which  may  increase  the  tension  within  the  bone, 
the  susceptibility  of  the  patient,  and  the  strain  to  which  the 
weakened  part  is  subjected.  This  sensitiveness  is  first  indicated 
by  the  involuntary  adaptation  of  the  body  to  the  weakiless  of  the 
affected  joint,  or,  as  popularly  expressed,  the  patient  favors  the 
leg. 

The  important  symptoms  of  disease  of  the  hip-joint,  in  the 
sense  of  attracting  attention  to  the  affection,  are  jjfwi  and  limp. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  297 

Of  the  two,  pain  is  much  the  less  significant.  Hip  disease  is  by 
no  means  a  painful  disease,  and  although  patients  are  often 
brought  for  treatment  because  of  pain,  it  is  usually  apparent, 
on  examination,  that  the  disease  must  have  existed  long  before  the 
acute  exacerbation  called  attention  to  its  serious  character.  Even 
in  cases  in  which  the  disease  is  far  advanced,  one  may  be  assured 
that  the  patient  has  never  complained  of  pain. 

Pain.  The  characteristic  pain  of  hip  disease  is  "  pain  in  the 
knee,"  referred,  as  is  the  pain  of  Pott's  disease,  to  the  more  im- 
portant distribution  of  the  nerves,  whose  filaments  are  irritated 
by  the  local  process.  The  hip-joint  is  supplied  by  the  anterior 
crural,  the  sciatic,  and  the  obturator  nerves,  but  the  pain  is  more 
often  referred  to  the  distribution  of  the  last,  thus  to  the  inner 
side  of  the  knee.  Pain  so  persistently  referred  to  the  knee  is 
misleading,  and  patients  are  often  treated  for  obscure  affections  of 
this  joint  long  after  an  examination  of  the  hip  would  have  made 
the  diagnosis  evident. 

The  pain  of  hip  disease  is  induced  by  sudden  or  unguarded 
movements,  or  by  injury  ;  therefore,  in  many  instances,  it  is 
rather  an  occasional  than  a  constant  symptom.  Persistent  pain 
almost  always  indicates  the  increased  tension  either  within  the 
bone  or  within  the  joint  that  accompanies  abscess  formation. 

Night  Cry.  Pain  at  night  is  of  importance,  as  it  more  often 
attracts  attention  than  the  occasional  complaint  of  discomfort 
during  the  day.  It  is  a  common  symptom  when  the  disease  is 
at  all  acute  in  character,  and  it  is  often  present  when  pain,  dur- 
ing the  period  of  activity,  is  apparently  absent.  It  may  be 
inferred,  as  an  explanation  of  this  symptom,  that  the  joint  grad- 
ually becomes  more  sensitive  under  the  strain  of  use  during  the 
day,  and  that  the  relaxation  of  the  voluntary  and  involuntary 
protection  of  the  muscles  allows  sudden  movements  that  excite 
spasmodic  muscular  contractions,  which  force  the  sensitive  parts 
against  one  another.  This  causes  a  sharp  cry.  If  the  disease 
is  acute,  the  child  is  usually  awakened  and  is  found  holding  the 
thigh  with  the  hands  or  pressing  upon  the  limb  with  the  other 
foot,  the  evidence  of  pain  being  unmistakable.  In  the  less  sen- 
sitive conditions  the  patient  does  not  wake  after  crying  out,  but 
simply  moans  or  is  restless  for  a  time.  If  awakened  it  makes  no 
complaint  of  pain  and  the  cry  is  supposed  to  be  caused  by  a  "  bad 
dream."  This  cry  may  be  repeated  several  times,  more  often  in 
the  early  part  of  the  night. 

Direct  local   pain  and  sensitiveness   to   pressure  are  unusual 


298  OE THOPEDIC  S  UB  GER  Y. 

unless  the  disease  is  acute  in  character,  or  unless  the  tissues 
overlying  the  joint  are  implicated,  as  in  abscess  formation. 

Limp.  The  limp  is  the  most  important  of  what  may  be  classed 
as  the  preliminary  signs  of  the  disease.  A  limp  is  a  change  in 
the  rhythm  of  the  gait,  a  long  step  alternating  with  a  shorter 
step.  It  is  evident  that  any  interference  with  the  function  of 
the  limb  will  cause  this  irregularity  which  can  be  concealed  or 
diminished  only  by  accommodating  the  normal  member  to  its 
disabled  fellow.  Thus  an  inequality  in  length,  or  a  limitation  of 
motion  in  the  joint,  or  distortion,  or  weakness  or  pain,  may  cause 
an  arrhythmical  gait.  Several  of  these  factors  may  be  combined 
in  the  causation  of  the  final  disability  of  hip  disease,  but  in  the 
beginning,  the  limp  is  due  rather  to  sensitiveness  than  to  any 
marked  restriction  of  function.  Thus  the  patient  favors  the 
joint  by  resting  on  the  limb  for  a  shorter  time  than  on  its  fellow, 
and  by  bearing  more  weight  upon  the  front  of  the  foot  than  upon 
the  heel.  If  the  joint  is  very  sensitive,  the  patient  may  bear 
practically  all  the  weight  upon  the  front  of  the  foot,  slight  plantar 
flexion  at  the  ankle  being  combined  with  slight  flexion  at  the 
knee  and  hip ;  thus  the  jar  of  direct  impact  of  the  heel  upon  an 
extended  leg  is  avoided. 

The  limp  is  a  constant  symptom  of  hip  disease  that  is  more 
or  less  noticeable  according  to  the  character  of  the  disease  ;  it  is 
even  subject  to  daily  variations  in  the  same  patient,  being,  as  a 
rule,  more  apparent  in  the  morning  or  on  changing  from  an 
attitude  of  rest  than  during  activity.  The  limp  may  be  inter- 
mittent even,  although  it  is  probable  that  in  most  instances 
some  change  from  the  normal  gait  might  be  detected  by  a  prac- 
tised eye. 

The  other  symptoms  of  disease  of  the  hip-joint  are  more  prop- 
erly physical  signs  that  become  evident  on  examination.  These 
are  :  stiffness,  distortion,  change  of  contour  of  the  hip,  atrophy. 

Stiffness,  due  to  reflex  muscular  spasm,  is  by  far  the  most 
important  sign  of  the  disease.  It  is  the  instinctive  expression  of 
the  inability  of  the  joint  to  perform  its  full  function  and  espe- 
cially to  allow  the  full  range  of  motion  which  puts  more  strain 
upon  the  bones  and  the  other  components  of  the  joint.  It  is  the 
first  and  the  last  sign  of  disease  ;  it  probably  precedes  the  limp, 
and  it  remains  long  after  pain  has  ceased  to  be  a  symptom,  and 
until  repair  is  complete. 

Reflex  muscular  spasm  limits  motion  in  every  direction  to  a 
greater  or  less  degree.      At  an  early  stage  of    the  disease    the 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  299 

motion,  whether  voluntary  or  passive,  may  be  perfectly  free 
throughout  three-fourths  of  its  normal  range,  but  when  the  limit 
allowed  by  the  muscular  protection  is  reached  motion  is  checked 
by  a  peculiar  elastic  resistance.  If  an  attempt  is  made  to  force 
the  limb  beyond  the  limit  set  by  the  muscular  resistance  the  entire 

Fig.  183. 


Apparent  lengthening.     Fixed  abduction  of  45°.    When  the  anterior  superior  spines  are  on 
the  same  plane,  as  in  the  illustration,  the  deformity  is  evident.    (See  Fig.  184.) 

body  follows  the  movement.  The  contraction  of  the  surrounding 
muscles,  including  those  of  the  trunk  even,  may  be  appreciated 
by  the  eye  and  by  the  hand,  and  the  expression  of  the  patient's 
face  shows  discomfort  and  apprehension. 

The  degree  of  muscular  spasm  corresponds  to  the  sensitiveness 
of  the  joint  rather  than  to  the  area  of  the  destructive  disease. 


300  OBTHOPEDIC  S UB QEB  Y. 

Thus  it  may  vary  from  day  to  day  and  even  from  hour  to  hour, 
and  in  the  acute  exacerbations  of  the  disease  motion  may  be  for 
a  time  so  absolutely  restricted  as  to  simulate  anchylosis. 

Reflex  muscular  spasm  is  an  infallible  sign  of  a  sensitive  joint  ; 
it  is,   of  course,   a  symptom  not    confined   to  the  tuberculous 

Fig.  184.  Fig.  185. 


Apparent   lengthening.    When  the   dis-  Right-angle  flexion  in  hip  disease  partly 

torted  limh  is  brought  to  the  median  line  concealed  by  the  compensatory  lordosis  and 

the  pelvis  is  so  tilted  that  the  abducted  by  the  flexion  at  the  linee  and  ankle, 
leg  seems  longer.    (See  Fig.  183.) 

process,  but  unless  it  be  the  direct  effect  of  injury  it  indicates 
disease,  and  if  this  disease  be  chronic  and  confined  to  a  single 
joint  it  is,  in  childhood  at  least,  almost  always  tuberculous  in 
character.  In  the  early  stage  of  hip  disease  the  restriction 
of  motion  is  caused  almost  entirely  by  reflex  muscular  spasm,  as 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  301 

is  shown  by  the  fact  that  when  the  patient  is  anaesthetized  the 
range  of  motion  becomes  practically  free.  As  the  destructive 
process  progresses  motion  is  still  further  restrained  by  adhesions 
and  contractions  within  and  without  the  joint. 

Distortion  of  the  Limb.  Persistent  reflex  muscular  spasm  is 
always  accompanied  by  a  certain  change  in  the  attitude  of  the 
limb,  slight  ilexion  being  the  earliest  indication  of  distortion  in 
disease  of  the  hip,  as  at  every  other  joint.  "With  this  flexion 
there  is  usually  abduction  and  slight  outward  rotation  of  the  limb. 

Flexion,  Abduction,  and  Outward  Rotation.  Appar- 
ent Lengthening.  This  is  the  passive  attitude  or  the  attitude 
of  rest  in  the  normal  condition,  and  in  disease  it  shows  the 
instinctive  adaptation  of  the  limb  to  a  sensitive  joint  which  is 
still  capable  of  a  certain  amount  of  work.  The  flexion  lessens 
the  direct  jar  and  the  abduction  throws  the  limb  aside,  as  it  were, 
from  the  active  attitude,  making  it  a  prop  and  adjunct  of  its 
fellow  instead  of  an  active  aid  in  the  propulsion  of  the  body. 
This  attitude  is  not  voluntarily  assumed  by  the  patient;  it  is 
involuntary  and  persistent.  The  limb  is  apparently  lengthened, 
because  it  is  held  away  from  the  axis  of  the  body,  and  in  order 
to  bring  it  into  the  middle  line  and  parallel  to  its  fellow  the 
pelvis  must  be  tilted  downward  on  the  diseased  side  and  upward 
on  the  other.  The  sound  leg  is  drawn  upward  and  the  affected 
leg  is  lowered  according  to  the  degree  of  abduction  (Fig.  184). 
If,  however,  the  anterior  superior  spines  of  the  pelvis  be  placed 
upon  the  same  plane,  the  distortion  becomes  evident  (Fig.  183). 
Thus  the  deformity  of  the  limb  is  concealed  or  compensated  by  a 
tilting  of  the  pelvis  which  twists  the  lumbar  spine  into  a  lateral 
convexity  toward  the  lower  side. 

In  the  same  manner  persistent  flexion  of  the  leg  is  concealed 
by  a  tilting  of  the  pelvis  forward,  and  by  an  increased  hollow- 
ness  or  lordosis  of  the  lumbar  region  (Fig.  185).  Normally,  in 
childhood  at  least,  the  lumbar  spine  and  the  popliteal  surface  of 
the  knee  should  touch  the  table  when  the  patient  lies  upon  the 
back,  but  if  the  thigh  is  fixed  in  flexion  the  lumbar  region  must 
be  arched  and  raised  from  the  table  when  the  leg  rests  upon  it. 
Thus,  in  order  to  make  the  flexion  apparent,  the  lumbar  spine 
must  be  forced  to  touch  the  table,  and  this  is  possible  only  when 
the  limb  is  raised  to  a  degree  corresponding  to  the  deformity 
(Fig,  186).  If  the  spine  were  rigid,  as  in  spondylitis  deformans, 
this  compensation  would  be  impossible,  and  if  the  patient  were 
placed  upon  his  back   the  log  could  not  be  brought  down  to  the 


302 


ORTHOPEDIC  SURGERY. 


table ;  or  if  both  limbs  were  distorted,  as  is  sometimes  the  case 
when  both  hip- joints  are  diseased,  the  limbs  would  remain  widely 
separated  or  crossed  over  one  another,  according  to  the  character 
of  the  deformity. 

Flexion,  Adduction,  and  Inward  Eotation.  Apparent 
Shortening.  If  the  disease  is  of  a  more  acute  type,  and  if 
locomotion  be  permitted,  the  attitude  usually  changes  to  one  of 
increased  flexion,  and  adduction  and  inward  rotation  replace 
abduction  and  outward  rotation.  This  attitude  is  an  indication 
that  the  joint  is  so  disabled  as  to  be  of  little  use,  thus  the  limb 
is  instinctively  drawn  into  a  more  protected  attitude  where  it 
may  be  used  as  little  as  possible.  If  the  patient  is  confined  to 
the  bed,  or  does  not  walk,  as  in  hip  disease  in  infancy,  the  atti- 


FiG.  186. 


The  degree  of  fixed  flexion  is  shown  when  the  lumbar  spine  is  held  in  contact  with  the  table 
by  flexing  the  other  thigh. 


tude  of  abduction  may  persist,  although  the  muscular  spasm  may 
be  intense.  Thus  it  would  appear  that  locomotion  has  a  distinct 
influence  on  the  character  of  the  distortion. 

Adduction  causes  apparent  or  practical  shortening ;  for  in 
order  to  bring  the  adducted  limb  to  the  middle  line  of  the  body 
and  parallel  with  its  fellow,  the  pelvis  must  be  tilted  upward  on 
the  affected  side  and  downward  on  the  other,  the  lumbar  spine 
bending  with  the  convexity  toward  the  lower  side  (Figs.  188  and 
191).  If  the  level  of  the  pelvis  be  restored,  the  adducted  limb 
will  be  crossed  over  its  fellow,  and  the  deformity  is  made  evident 
(Fig.  187). 

As  has  been  stated,  the  attitude  of  flexion,  adduction,  and 
inward  rotation,  if  it  appears  early  in  the  disease,  is  usually  an 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


30.^ 


indication  of  acute  and  disabling  pain  and  of  corresponding  in- 
tensity of  muscular  spasm.  But  in  most  instances  it  is  associated 
with  the  later  and  destructive  stage  of  the  disease,  and  it  by  no 


Fig.  187. 


Fig.  188. 


Apparent  shortening.  The  adduction  of  the 
right  thigh  is  made  evident  by  the  involun- 
tary crossing  of  the  legs  when  the  anterior 
superior  spines  are  on  the  same  plane. 


Apparent  shortening.  When  the  adducted 
limb  is  placed  in  the  line  of  the  body,  the 
pelvis  is  tilted  upward  on  the  adducted  side 
and  downward  on  the  other.  The  patient  has 
compensated  for  the  apparent  shortening  by 
flexing  the  knee  on  the  sound  side.  This 
does  not  appear  in  the  photograph. 


means  indicates  that  the  preceding  symptoms  have  been  more 
than  ordinarily  acute.  In  fact,  it  is  the  attitude  characteristic 
of  a  so-called  "natural  cure"  (Fig.  189)  when  mechanical  treat- 
ment has  not  been   employed.     It  more  often  accompanies  the 


304 


ORTHOPEDIC  SURGERY. 


Fig.  189. 


later  course  of  the  disease,  because  its  causes  are  in  great  degree 

mechanical. 

This  is  illustrated  by  Koenig's  statistics  of  499  cases  of  hip 

disease. 

In  267  cases  the  limb  was  abducted,  and  in  31  per  cent,  of 

these  there  was  actual  shortening. 

In  232  cases  adduction  was  pres- 
ent, and  in  70  per  cent,  the  limb  was 
shorter  than  its  fellow.^ 

The  mechanics  of  the  distortion 
will  be  made  clearer  if  it  be  com- 
pared to  the  deformity  symptomatic 
of  dorsal  dislocation  of  the  hip.  In 
this  displacement  the  femur,  forced 
upward  and  backward  upon  the  pel- 
vis, is  fixed  in  an  attitude  of  extreme 
flexion,  adduction,  and  inward  rota- 
tion. Each  of  the  destructive  changes 
of  hip  disease,  the  enlargement  of 
the  acetabulum,  the  depression  of 
the  neck  of  the  femur,  and  the  ero- 
sion of  the  head  of  the  bone,  is  ac- 
companied by  an  elevation  of  the 
femur  upon  the  pelvis  or  an  approxi- 
mation to  a  dorsal  displacement  (Fig. 
190).  If  this  displacement  occurs 
suddenly,  as  in  certain  cases  of  acute 
disease  attended  by  effusion  and 
rupture  of  the  capsule,  the  limb  im- 
mediately assumes  an  attitude  typical 
of  dorsal  dislocation ;  but  in  the  or- 
dinary form  of  disease  the  changes 
are  very  gradual ;  the  pelvis  and 
the  femur,  being  in  most  instances 
The  final  efifeet  of  hip  disease  when    undeveloped,  iiiore  easily  accommo- 

untreated.     The   natural  cure,   with  r       '  ^ 

flexion  and  adduction.    Compensatory     date  thcmselvCS  tO  the  changed   COn- 

recurvation  of  the  knee  on  the  sound      ,..  .ij.;i  .       itj.      j.*„ 

side  is  also  shown.  ditions,  SO  that  the  actual  distortion 

is  less  marked  than  in  a  similar  sub- 
luxation of  traumatic  origin  in  the  adult,  but  the  simile  will 
serve  to  illustrate  the  mechanical  causes  of  distortion,  and  why 


1  Koenig.    Das  Hoeftgelenk,  Berlin,  1902. 


TUBERCULOUS  DISEASE  OF  THE  HIP -JOINT. 


305 


such  deformity  may  reour  after  correction,  even  though  the  disease 
has  entirely  disappeared. 

Outward  rotation  of  the  limb  is  usually  associated  with  abduc- 
tion, and  inward  rotation  with  adduction,  but  in  certain  instances 


Fig.  190. 


Fig.  191. 


Untreated  hip  disease.  Flexion 
deformity  to  nearly  a  right  angle 
with  the  body.  Trochanter  two 
inches  above  N^laton's  line.  Com- 
pensatory lordosis. 


Stage  of  apparent  shortening.  The  left  limb 
is  adducted  35°,  mailing  an  apparent  shortening 
measured  from  the  umbilicus  of  more  than  two 
inches.  In  order  to  reduce  the  obliquity  of  the 
pelvis,  the  adducted  leg  must  be  crossed  over  its 
fellow.  (See  Fig.  187.)  The  apparent  shortening 
is  compensated  by  the  flexion  at  the  knee  on 
the  sound  side.  This  is  not  made  clear  in  the 
photograph. 


outward  rotation  may  be  combined  with  adduction  and  vice  versa. 
These  irregular  attitudes  are  more  often  observed  in  cases  that 

20 


306  ORTHOPEDIC  S UBGEB  Y. 

have  received  mechanical  or  operative  treatment  than  in  those 
in  which  the  disease  has  pursued  its  natural  course. 

As  has  been  stated,  the  distortions  of  the  early  course  o£  hip 
disease  are  caused  almost  entirely  by  muscular  contraction  which 
relaxes  under  the  influence  of  an  ansesthetic,  but  after  a  time  the 
attitude  is  still  further  assured  by  accommodative  changes  in  the 
muscles  and  fasciae,  and  by  contractions  and  adhesions  about  the 
capsule.  Thus  an  attitude  that  was  originally  a  symptom  may 
persist  after  the  cure  of  the  disease. 

One  may  conclude  then  that  flexion  is  practically  an  invari- 
able symptom  in  hip  disease  because  complete  extension, '  the 
attitude  that  puts  most  strain  upon  the  joint,  is  first  restricted. 
Flexion  in  the  milder  or  in  the  earlier  class  of  cases  is  usually 
combined  with  abduction  and  outward  rotation,  the  attitude  of 
inactivity.  Increased  flexion,  accompanied  by  adduction  and 
inward  rotation  in  the  early  stage,  is  an  indication  of  a  more 
acute  phase  of  the  disease.  If  the  attitude  is  retained  for  a  time 
it  becomes  fixed  by  accommodative  changes  in  the  tissues ;  thus 
the  distortion  is  not  unusual  in  cases  in  which  the  damage  to  the 
joint  may  be  very  slight,  as,  for  example,  when  it  follows  rheu- 
matism or  some  form  of  infectious  arthritis.  But  in  most  in- 
stances the  attitude  is  indicative  of  more  advanced  disease  and  of 
destructive  changes  within  the  joint. 

Changes  in  the  Contour  of  the  Hip.  In  the  early  stage  of  the 
disease  the  changes  in  contour  are  caused  in  great  part  by  the 
attitude  of  the  limb.  If,  as  is  usual,  it  is  flexed,  abducted,  and 
rotated  outward,  the  buttock  appears  somewhat  flatter  and  broader 
than  its  fellow.  The  gluteofenioral  fold  is  lower  because  of  the 
tilting  downward  of  the  pelvis  and  it  is  shallower  because  of  the 
flexion.  If  the  thigh  is  adducted,  the  gluteal  fold  will  be  ele- 
vated and  shortened.  On  the  anterior  aspect,  the  inguinofemoral 
fold  is  deepened  and  lengthened  by  flexion  and  adduction,  while 
abduction  makes  it  less  noticeable.  Hoffman  has  called  attention 
to  the  fact  that  the  genitals  and  the  intergluteal  fold  point  toward 
the  adducted  and  away  from  the  abducted  thigh.  Adduction 
makes  the  trochanter  more  prominent,  and  abduction  makes  it 
less  prominent. 

To  these  primary  changes  in  the  appearances  must  be  added 
the  effect  of  atrophy  or  of  infiltration  and  swelling,  due  directly 
to  the  disease.  A  certain  amount  of  swelling  indicating  effusion 
into  the  joint  is  often  apparent  in  the  inguinofemoral  region,  and 
infiltration  of  the  deeper  tissues  is  sometimes  evident  on  palpation. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  307 

In  such  cases  there  is  usually  a  certain  sensitiveness  to  deep  pressure 
behind  or  in  front  of  the  trochanter.  Palpable  or  evident  abscess 
is  unusual  in  the  early  stage  of  the  disease. 

Atrophy.  Atrophy  is  an  important  sign  of  joint  disease.  It  is 
often  appreciable  to  the  eye  and  to  the  hand,  and  it  is  always 
demonstrable  by  measurement.  It  is  an  important  symptom, 
because,  if  well  marked,  it  shows  that  the  disease  must  have 
existed  for  some  time,  whatever  may  be  the  statement  of  the 
patient's  relatives. 

The  atrophy  affects  the  muscles  of  the  entire  limb,  although  it 
is  somewhat  more  marked  in  the  muscles  of  the  thigh  than  in 
the  calf.  In  the  ordinary  case  of  hip  disease  in  childhood,  when 
the  patient  is  first  brought  for  treatment,  it  averages  from  one- 
half  to  one  inch  in  the  thigh  and  somewhat  less  in  the  calf.  As 
has  been  stated  elsewhere,  atrophy  of  muscles  is  usually  accom- 
panied by  a  corresponding  atrophy  of  bone  as  well. 

The  Causes  of  Ateophy.  The  causes  of  the  atrophy 
secondary  to  joint  disease  have  been  the  subject  of  much  discus- 
sion. As  it  is  associated  with  an  increase  of  the  reflex  excita- 
bility of  the  muscles,  and  as  it  often  progresses  with  great  rapidity, 
the  prevailing  theory  has  been  that  of  Vulpian  and  Charcot,  that 
it  is  of  nervous  or  reflex  origin.  According  to  this  hypothesis 
the  atrophy  is  the  result  of  a  change  in  the  trophic  centres  of  the 
spinal  cord,  "  an  inertia,"  due  to  irritation  of  the  articular  fila- 
ments of  the  nerves. 

Another  theory  has  been  advanced  by  Saborin.  As  branches 
of  the  same  nerves  are  distributed  to  the  joint  and  to  the  sur- 
rounding muscles,  he  suggests  that  the  atrophy  may  be  caused  by 
a  direct  implication  of  the  nerves  whose  filaments  are  involved  in 
the  disease  of  the  joint — a  form  of  molecular  neuritis. 

Admitting  that  the  secondary  causes  of  atrophy  are  somewhat 
obscure,  one  cause,  and  by  far  the  most  important,  is  very  evi- 
dent. This  is  physiological  disuse,  and  thus  diminished  nutrition 
of  the  limb  which  has  become  incompetent  to  carry  out  its  full 
function.  Atrophy  is  a  constant  symptom  of  simple  disuse  in 
the  absence  of  disease.  If  a  bone  has  been  broken,  atrophy  of 
the  surrounding  muscles  is  observed.  If  anchylosis  of  a  joint 
occurs  from  any  cause,  whether  it  be  from  injury  or  disease, 
atrophy  of  the  muscles,  whose  function  has  been  abolished,  fol- 
lows. Even  the  atrophy  caused  by  disease  of  the  hip-joint  is 
greater  when  the  limb  has  been  fixed  in  apparatus  than  when 
none  has  l)een  applied,  although  the  treatment  has  allayed  the 


308  ORTHOPEDIC  SURGERY. 

pain  and  has  checked  the  progress  of  the  disease.  This  point  is 
illustrated  by  the  observations  of  Brackett/  who  contrasted  the 
atrophy  of  hip  disease  in  two  groups  of  patients,  in  one  of  which 
motion  had  been  permitted,  while  in  the  other  fixation,  as  com- 
plete as  possible,  had  been  employed.  In  the  first  group  the 
average  of  atrophy  was  but  1  per  cent,  of  the  volume  of  the 
thigh  and  0.89  per  cent,  of  that  of  the  leg,  as  contrasted  with 
23  per  cent,  and  17  per  cent,  in  the  second  class. 

It  has  been  stated  in  objection  to  this  theory,  by  those  who 
understand  disuse  as  meaning  only  relief  from  motion  and 
weight  bearing,  that  atrophy  is  observed  even  though  the  patient 
be  confined  to  the  bed,  but  under  these  conditions  there  would 
be  relative  disuse  of  a  limb  if  motion  caused  pain  or  discomfort, 
in  degree  proportionate  to  the  intensity  of  the  local  disease. 
Meanwhile  a  lesser  atrophy  might  be  demonstrated  in  the  sound 
limb  that  had  been  deprived  of  its  normal  stimulus,  just  as 
relative  hypertrophy  of  a  limb  which  has  to  perform  double 
function  is  often  observed. 

The  atrophy  caused  by  physiological  disuse  and  diminished 
nutrition  affects  all  the  components  of  the  limb.  The  skin 
becomes  thinner,  the  muscles  lose  in  volume,  the  contractile  sub- 
stance is  replaced  in  part  by  fat  and  by  fibrous  tissue,  and  the 
medullary  canals  of  the  bones  enlarge  at  the  expense  of  the 
cortical  substance. 

In  childhood,  the  period  of  rapid  development,  disuse  often 
causes  a  retardation  in  growth  of  the  entire  extremity.  This 
may  be  apparent  in  the  foot  when  it  is  placed  by  the  side  of  its 
fellow,  while  the  diminished  growth  in  the  length  of  the  limb 
may  be  demonstrated  by  measurement.  Brackett,  in  a  series  of 
cases,  found  this  shortening  to  be  distributed  as  follows  :  average 
loss  of  the  femur  Q.Q  per  cent,  and  of  the  tibia  5.4  per  cent,  of 
the  normal  length. 

This  atrophy,  the  direct  result  of  the  disease  and  of  the  long- 
continued  disuse  during  the  period  of  repair,  becomes  less  notice- 
able after  function  is  resumed,  the  degree  of  final  inequality 
depending  upon  the  severity  of  the  disease,  the  duration  of  the 
treatment,  and  upon  the  impairment  of  function.  But  even 
when  free  motion  in  the  joint  is  retained,  a  certain  amount  of 
atrophy  always  persists  and  the  loss  in  growth  is  never  replaced. 
If  motion  is  completely  abolished  the  muscles  about  the  joint  lose 

"'  Transactions  American  Orthopedic  Association,  vol.  iv. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


309 


in  bulk  in  proportion  to  the  disuse  of  their  normal  function  ;  where- 
as, the  bones  of  the  limb  which  are  still  used  to  support  the  weight 
retain  to  a  greater  degree  their  normal  size  and  length.  Combined 
with  the  atrophy  of  the  weak  limb  there  is  a  relative  hypertrophy 
of  the  sound  leg  which  is  forced  to  assume  more  than  its  share  of 
work. 

Fig.  192. 


Early  stage  of  disease  of  the  left  hip-joint  (to  the  right  in  the  picture)  of  the  synovial  type, 
showing  irregularity  in  the  shape  of  the  acetabulum. 

Actual  Shortening.  Actual  shortening  of  the  limb  is  a 
c  jmmon  effect  of  hip  disease,  but  it  can  hardly  be  called  a  symp- 
tom, for  it  is  not  present  at  the  onset  of  the  disease. 

The  causes  of  actual  shortening  may  be  classified  as  : 

1.  Disuse  of  the  limb. 

2.  The  effect  of  the  disease  upon  the  epiphysis  of  the  head  of 
the  femur. 


310 


ORTHOPEDIC  SURGERY. 


3.  The  more  general  destructive  effects  of  the  disease  that 
cause  upward  displacement  of  the  femur. 
(a)  Erosion  of  the  head. 
(6)  Erosion  of  the  acetabulum. 
(c)  Depression  of  the  neck  of  the  femur. 
Disuse,  throughout  a  long  period  of  treatment,  may  cause  a 
certain  amount  of  shortening  of  the  entire  limb.     To  this  the 


Fig.  193. 


Advanced  disease,  showing  wandering  of  the  acetabuhim  and  the  obliquity  of  the  pelvis  due 
to  adduction.    Actual  shortening  one  inch,  apparent  shortening  three  Inches. 


shortening  of   the   bones   of  the   leg  and  of  the  foot  may   be 
attributed  in  great  part.     If  the  epiphysis  of  the  head  of  the 
femur  is  destroyed  in  whole  or  in  part  or  if  the  disease  hastens 
its  union  with  the  neck  a  certain  loss  of  growth  must  follow. 
This  is,  of  course,   slight  in    degree,   because  this  epiphysis  is 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


311 


relatively  unimportant  compared  with  that  at  the  lower  extremity 
of  the  femur.  From  these  two  causes,  the  atrophy  of  disuse  and 
the  effect  of  the  disease  upon  the  epiphysis,  relative  shortening 
of  the  limb  may  increase  after  the  disease  is  cured. 

Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of 
the  acetabulum  are  usually  combined  in  those  cases  in  which  the 
shortening  is  in  part  dependent  on  upward  displacement  of  the 
trochanter  (Fig.  1 80).  Depression  of  the  neck  of  the  femur  to 
an  appreciable  degree  is  less  common.  Elevation  of  the  trochan- 
ter, due  to  one  or  more  of  these  causes,  a  form  of  subluxation, 
is  very  common,  particularly  so  in  those  cases  in  which  the  pro- 
tective treatment  has  been  inefficient.  Greater  displacement 
follows  fracture  of  the  weakened  neck  and  complete  absorption 
of  the  head,  and  occasionally  a  fairly  normal  femur  may  be 
actually  dislocated  as  a  result  of  sudden  effusion  into  the  joint 
with  rupture  of  the  capsule — a  form  of  pathological  dislocation. 

Eetardation  of  Growth.  As  has  been  stated,  all  the  com- 
ponents of  the  limb  are  affected  by  the  retardation  of  the  growth. 
Brackett's  observations  on  this  point  have  been  mentioned,  and 
the  accompanying  table,  showing  the  relative  measures  of  the 
bones  in  cases  under  treatment  by  Dollinger,^  of  Budapest,  presents 
the  subject  in  a  convenient  form  : 


Age  at 

Duration  of 

Length  of 

Length  of 

inception. 

disease. 

femur  in  cm. 

tibia  in  cm. 

No.  of 

Diflfer- 
ence. 

Diflfer- 

case. 

Years. 

Months 

Years.  |  Months 

1 

Dis- 
eased. 

Normal 

Dis- 
eased. 

Normal 

ence. 

1 

8 

6 

6 

2sy^ 

28 

+K 

24 

24 

2 

3 

4 

8 

23 

24 

1 

19 

19 

3 

2 

10 

"i 

8 

24 

24 

19.5 

19.5 

4 

5 

2 

29 

30 

1 

23.5 

23.5 

5 

6 

2 

27 

28 

1 

23 

23 

6 

7 

2 

32 

33 

1 

27 

27 

7 

9 

2 

37 

37 

30 

30 

8 

1 

4 

22 

24 

"2 

18.5 

19 

0.'5 

9 

13 

4 

38 

41 

3 

34 

34 

10 

4 

'6 

5 

32 

34 

2 

27 

27 

11 

23^ 

6 

26 

27 

1 

213^ 

23 

i" 

12 

is 

7 

38 

40 

2 

33 

38 

13 

2 

8 

35 

36 

1 

28 

28 

14 

6 

8 

38 

38 

31 

32 

15 

11 

8 

40 

44 

"4 

34 

34 

16 

5 

10 

45 

46 

1 

17 

5 

11 

41 

44 

3 

31 

37 

6 

18 

6 

34 

44 

48 

4 

36 

39.5 

3.5 

19 

2 

18 

36 

46 

10 

38 

38 

20 

2 

28 

44>^ 

45 

K 

37.5 

37.5 

A  similar  investigation  of  thirty-three  cases  under  treatment 
at  the  Hospital  for  Ruptured  and  Crippled,  New  York,  has  been 
made  recently  by  Taylor.     In  these  cases  the  shortening  of  the 


1  Zeits.  f.  Orth.  Chir.,  1892,  Bd.  i. 


312 


OR  THOPEDIC  S  UB  GEB  Y. 


bones  was  found  to  be  more  generaly  distributed  than  in  those 
reported  by  Dollinger,  as  is  illustrated  by  the  following  table  : 


Sex. 

Age. 

Side. 

Dura- 
tion of 
disease, 
years. 

Dura- 
tion of 
treat- 
ment, 
years. 

Abscess 

Shortening  in  inches. 

Case. 

Entire 
limb. 

Femur. 

Tibia. 

Foot. 

Patella. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

F. 
M. 
M. 
M. 
M. 
F. 
F. 
M. 
F. 
F. 
M. 
F. 
F. 

3K 

5 
5 

13 

7 

7 
11 

9 

Left 

Right 

Left 

Right 

Lett 

LeJt 

Right 

Right 

Left 

Left 

Right 

Right 

Left 

1 

2 
2 

3 

hi 

3!^ 

3K 
3>i 

f 

33^ 
3^ 

No 
No 
No 
No 
Yes 
No 
No 
No 
No 
No 
Yes 
No 
No 

1 
11 

X 

i 

% 
3^ 

J 
1 

Average 

7 

2>^ 

2 

% 

Yb 

K 

J< 

y 

14 
15 
16 
17 
18 
19 
20 
21 
22 
23 

M. 
F. 
F. 
F. 
F. 
F. 
F. 
M. 
F. 
M. 

7 

8J^ 
12 
11 
13 
12 
10 
14 
15 

9K 

Right 

Right 

Right 

Right 

Left 

Left 

Left 

Left 

Right 

Right 

4 
4 
5 
fi 

6 

/ 
7 
7 

4 

4 
4 
4 
3 
4 
4 

X 

5 

No 
No 
Yes 
Yes 
No 
No 
No 
Yes 
No 
Yes 

1 
1 
35i 

2 

IK 
2^ 
fA 
IK 

P 
1 

X 

X 

15< 

H 

X 

\ 

X 
X 

Average 

11 

5}^ 

Wt 

1% 

% 

% 

y. 

«^ 

24 
25 
26 
27 
28 
29 
30 
31 
32 
33 

F. 
M. 
M. 
F. 
M. 
F. 

i;- 

F. 
F. 

F. 

13 
15 

10)^ 

18 

18 

15 

15 

15 

16 

21 

Right 

Right 

Right 

Right 

Right 

Left 

Right 

Right 

Left 

Left 

8 

9 

9 

9 
11 
11 
11 

UK 

14 
17 

7 
6 

X 

7 

10 
7 
5 

»x 

6 

Yes 
Yes 
No 
No 
Yes 
Yes 
Yes 
Yes 
No 
Yes 

2k: 

4^ 

l>f 

2 
3 

1 
3 
1^ 

2^ 

X 

2» 

1 

2>^ 

1 

X 

% 

k: 

1 

X 

1 
i 

Average        15 

11 

6 

23^ 

%                    1 

% 

—  Measurements  equal.  x  Measurements  not  taken. 

Measurements  of  the  femur  from  the  apex  of  the  great  trochanter  to  the  knee-joint.  Patella 
measured  transversely.  The  cases  are  grouped  according  to  the  duration  of  disease  and  the 
averages  are  given  separately  for  each  group. 

Dr.  Taylor  measured  also  ten  cases  of  unilateral  poliomyelitis, 
in  patients  of  an  average  age  of  thirteen  years,  with  an  average 
duration  of  disability  of  ten  years.  The  average  shortening  in 
these  cases  was  one  and  three-fourths  inches,  and  in  no  case  was 
it  greater  than  two  and  one-half  inches.  It  will  be  noted  that 
the  retardation  of  growth  in  this  group  corresponds  closely  with 
that  of  the  third  group  of  cases  of  hip  disease,  in  which  the  disa- 
bility was  of  about  the  same  duration.     Taylor  concludes  that 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  313 

the  retardation  of  growth  from  unilateral  hip  disease  in  childhood 
is  dependent  in  great  degree  upon  the  duration  of  the  disability 
and  upon  the  corresponding  restraint  of  function.  Similar 
observations  on  fifty  cases  of  hip  disease  have  been  recorded  by 
Hibbs.^  In  eleven  of  these  cases  the  femur  was  found  to  be 
slightly  longer  on  the  diseased  side. 

Actual  lengthening  of  the  limb  as  the  result  of  disease  is 
occasionally  observed  during  the  active  stage  of  the  disease, 
caused  it  may  be  inferred  by  granulations  within  the  acetabulum 
that  press  the  femur  outward  and  downward.  Actual  lengthen- 
ing of  the  femur  is  uncommon,  but  it  does  occur,  induced,  it  may 
be,  by  stimulation  of  the  growth  of  the  epiphysis  of  the  head ; 
but  the  most  extreme  instances  are  those  in  which  the  upper  por- 
tion of  the  shaft  of  the  femur  is  involved,  the  lengthening  being 
the  effect  of  an  irritative  hypertrophy.  This  is  more  commonly 
the  result  of  extra-articular  disease. 

General  Symptoms  of  the  Disease.  Debility.  If  the  disease 
is  suiiiciently  painful  to  cause  loss  of  sleep  and  to  affect  the 
appetite,  pallor  and  loss  of  flesh  and  strength  may  be  expected. 
It  must  be  borne  in  mind,  however,  that  the  patient  may  have 
been  "  delicate "  long  before  the  local  tuberculous  disease  was 
acquired.  At  all  events,  from  the  diagnostic  standpoint  at  least, 
the  local  disease  has  no  characteristic  influence  upon  the  general 
condition,  and  the  appearance  of  perfect  health  is  not  at  all 
unusual  among  patients  with  hip  disease. 

Fever.  It  is  probable  that  a  slight  elevation  of  temperature 
might  be  detected  in  a  large  proportion  of  the  patients,  and  in 
such  cases  actual  appreciable  fever  often  follows  overexertion  or 
injury.  Fever,  as  a  symptom  of  infected  abscess  in  the  later 
course  of  the  disease,  is,  of  course,  of  importance,  but  in  the  early 
stages  of  the  disease  the  record  of  the  temperature  would  be  of 
but  little  diagnostic  value. 

The  History  and  the  Method  of  Examination.  In  consider- 
ing the  differential  diagnosis  of  tuberculous  disease  of  the  hip- 
joint  one  should  keep  its  characteristics  in  mind.  It  is  a  chronic 
disease,  in  that  the  symptoms  may  have  been  present  for  weeks 
or  months  or  even  years  before  the  patient  is  brought  for  treat- 
ment. It  is  a  disease  confined  to  a  single  joint,  thus  differing 
from  rheumatism  and  similar  affections  in  which  several  joints 
are  involved.  It  does  not  get  well ;  thus  it  may  be  differentiated 
from  injury  and  from  the  minor  affections  that  simulate  some  of 

'  New  York  Medical  Journal,  December  16,  1899. 


314  OBTHOPEDTG  SURGERY. 

its  symptoms.  It  causes  a  limp.  It  is  accompanied  by  reflex 
muscular  spasm,  usually  by  a  certain  amount  of  deformity  and 
by  general  atrophy  of  the  muscles  of  the  limb. 

The  importance  of  the  inheritance  and  of  the  personal  history 
of  the  patient  has  been  mentioned  already  in  the  consideration 
of  Pott's  disease.  In  recording  the  history  in  this  as  in  all 
other  chronic  diseases  of  childhood  one  attempts  to  ascertain  the 
approximate  duration  of  the  pathological  process  rather  than  the 
duration  of  the  more  acute  symptoms  for  which  the  patient  has 
been  brought  for  treatment.  One  asks,  therefore,  when  the  child 
was  last  perfectly  well,  and,  bearing  in  mind  the  remission  of 
symptoms,  one  asks  if  limp  or  pain  had  been  noticed  at  any  time 
before  the  more  acute  symptoms.  In  the  history  there  is  almost 
invariably  mention  of  a  fall,  and  one  must  ascertain  whether  the 
fall  had  any  influence  in  the  causation  of  the  symptoms,  remem- 
bering that  the  weakness  and  interference  with  function  due  to 
joint  disease  more  often  cause  falls  than  falls  cause  joint  disease. 

Physical  Examination.  One  begins  the  physical  examination  by 
the  observation  of  the  general  condition  of  the  patient,  and  notes 
the  attitudes,  and  the  character  of  the  limp.  The  patient's  cloth- 
ing is  then  entirely  removed,  that  one  may  observe  the  contour 
of  the  part  and  the  general  influence  of  the  affection  upon  the 
mechanism  of  the  body.  The  patient  is  then  placed  on  his  back 
upon  a  table,  with  the  limbs  parallel  to  one  another,  so  that 
their  relative  length  and  size  may  be  observed.  If  the  pelvis  is 
level  when  the  limbs  are  parallel,  there  can  be  no  persistent 
abduction  or  adduction,  for  when  the  two  anterior  superior  spines 
are  on  the  same  plane  such  distortion  is  always  evident.  If  the 
lumbar  spine  and  the  popliteal  surfaces  of  the  knees  rest  on 
the  table  simultaneously  it  shows,  too,  that  persistent  flexion  is 
absent.  One  next  tests  the  functions  of  the  hip-joints,  always 
beginning  with  the  sound  side  for  the  purpose  of  comparison, 
and  in  order  that  the  patient  may  become  accustomed  to  the 
manipulation  before  the  one  suspected  of  disease  is  tested.  Dis- 
ease within  a  joint  is  accompanied  by  muscular  spasm  that  limits 
motion  in  every  direction,  thus  differing  from  other  affections 
outside  the  joint  that  may  limit  its  motion  in  one  or  more  but 
not  in  all  directions. 

One  compares  the  flexion,  abduction,  adduction,  and  rotation 
of  the  limbs  while  the  child  lies  upon  its  back ;  it  is  then  turned 
upon  its  face  to  test  for  extension  by  holding  the  pelvis  flat  upon 
the  table  with  one  hand  while  the  thigh  is  gently  elevated  with 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  315 

the  other  (Fig.  16).  The  normal  range  of  extension  in  child- 
hood is  at  least  ten  degrees  backward  from  the  line  of  the  body, 
and  limitation  of  this  range  is  the  earliest  sign  of  approaching 
deformity  of  hip  disease.  It  may  precede  the  restriction  of  the 
extremes  of  motion  in  other  directions,  although  this  is  unusual, 
and  if  this  motion  is  unrestricted  disease  of  the  joint  may  be, 
practically  speaking,  excluded.  The  character  of  the  reflex 
spasm  that  limits  motion  and  the  indications  of  discomfort  when 
the  limit  has  been  reached  have  been  described. 

Measurements.  The  measurements  of  the  limbs  are  then  made. 
One  first  ascertains  the  actual  length  of  the  limbs  by  measur- 
ing from  the  anterior  superior  spines  of  the  pelvis  to  the  extrem- 
ities of  the  internal  malleoli,  actual  shortening  being,  of  course, 
absent  in  the  early  stage  of  the  disease.  The  second  measure- 
ment is  from  the  umbilicus  to  show  the  amount  of  apparent 
shortening  or  lengthening  that  may  be  present  if  the  limb  is  dis- 
torted. The  actual  length  of  the  limbs,  as  measured  from  the 
anterior  superior  spines,  is  not  changed  by  tilting  of  the  pelvis, 
but  as  the  umbilicus  is  in  the  middle  line  of  the  body  above  the 
pelvis,  measurement  from  this  point  simply  shows  the  actual  dis- 
tance to  the  malleoli.  Persistent  adduction  causes  compensatory 
obliquity  of  the  pelvis  ;  consequently  the  malleolus  on  the  affected 
side  is  drawn  upward  or  nearer  to  the  umbilicus,  while  the  other 
is  carried  downward  to  a  corresponding  distance  (Fig.  191).,  If, 
then,  the  measurements  from  the  umbilicus  to  the  malleoli  do  not 
correspond  relatively  with  those  from  the  anterior  superior  spines, 
when  the  limbs  are  parallel  and  in  the  median  line,  it  shows 
distortion  ;  adduction,  if  the  limb  is  relatively  shorter,  abduction, 
if  it  is  relatively  longer  than  is  shown  by  the  measurement  from 
the  anterior  superior  spine.  It  has  been  stated  that  the  meas- 
urement from  the  anterior  superior  spine  is  not  changed  by  dis-  , 
tortion.  It  is,  however,  shortened  slightly  by  outward  rotation, 
and  more  appreciably  by  abduction,  and  it  is  lengthened  some- 
what by  adduction.  This  is  explained  as  follows  :  When  the 
limb  is  in  the  line  of  the  body  the  trochanter  is  below  the  anterior 
superior  spine  from  which  the  measurement  is  made.  Abduction 
of  the  limb  raises  the  trochanter  toward  the  plane  of  the  anterior 
superior  spine,  and  consequently  lessens  the  distance  from  this 
point  to  the  extremity  of  the  limb.  Adduction,  on  the  contrary, 
lowers  the  trochanter  and  increases  the  distance  between  these 
two  points.  In  ordinary  cases  the  variation  from  this  source 
does  not  exceed  half  an  inch.     Flexion  of  one  thigh  causes  a  tilt- 


316 


ORTHOPEDIC  SURGERY. 


ing  forward  of  the  pelvis  that  lessens  the  distance  between  the 
anterior  superior  spine  and  the  malleolus  on  both  sides,  although 
not  to  an  equal  degree.  It  is  customary,  therefore,  if  the  flexion  is 
considerable,  to  raise  the  unaffected  limb  to  the  line  of  its  fellow 
in  making  the  comparative  measurements,  stating  in  the  record 
that  the  limbs  have  been  measured  at  the  angle  of  the  deformity. 
Method  of  Estimating  the  Degree  of  Distortion  of 
THE  Limb.  As  has  been  stated,  when  the  pelvis  is  level,  distor- 
tion of  the  limb  is  apparent,  and  the  degree  of  distortion  can  be 
measured  by  the  goniometer  (Fig.  187);  but  it  may  be  more 
easily  ascertained  by  "  Lovett's  table.  "^  This  method  is  described 
by  its  author  as  follows  : 

Table  I. — Distakce  between  Anterior  Superior  Spines  in  Inches. 


3 

33^ 

4 

4% 

5 

s^i 

6  eyj\ 

7 

7% 

8 

»% 

9 

9K 

10 

11 

12 

13 

Sab 

Vx 

5° 

4° 

4° 

3° 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

1° 

1° 

1° 

1° 

1° 

a 

J4 

10 

8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

■s 

o 

K 

14 

12 

11 

10 

8 

8 

7 

7 

6 

6 

5 

5 

5 

4 

4 

4 

3 

3 

1 

19 

17 

14 

13 

11 

10 

9 

9 

8 

7 

7 

7 

6 

6 

6 

5 

5 

4 

p. 

I'X 

25 

21 

18 

16 

14 

13 

12 

11 

10 

9 

9 

8 

8 

7 

7 

7 

6 

6 

1 

T^% 

30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

11 

10 

10 

9 

9 

8 

7 

7 

m 

36 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

11 

10 

10 

9 

8 

8 

"3 
S 

2 

42 

35 

30 

26 

23 

21 

19 

18 

16 

15 

14 

14 

13 

12 

12 

10 

10 

9 

a 
9. 

2'X 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

11 

10 

2% 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

11 

1 

2K 

38 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

a 
B 

3 

42 

35 

32 

29 

27 

25 

23 

22 

21 

19 

18 

18 

16 

14 

12 

SK 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15 

14 

3J4 

40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17 

16 

1 

s 

m 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18 

17 

,  4 

42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19 

18 

"  To  measure  by  this  method  the  patient  is  made  to  lie  straight 
with  the  legs  parallel.  Real  shortening  is  measured  with  the 
ordinary  tape  measure,  and  apparent  shortening  is  obtained  in 
the  same  way.  It  may  be  repeated  that  real  or  bony  shortening 
is  measured  from  the  anterior  superior  iliac  spines  to  each  mal- 
leolus, and  that  practical  shortening  is  found  by  a  measurement 
taken  from  the  umbilicus  to  each  malleolus.  The  difference  in 
inches  between  the  two  kinds  of  shortening  is  seen  at  a  glance. 


1  R.  W.  Lovett.    Boston  Medical  and  Surgical  Journal,  March  8, 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


317 


The  only  additional  measurement  necessary  is  the  distance 
between  the  anterior  superior  spines,  which  is  taken  with  the 
tape.  Turning  now  to  the  table  :  if  the  line  Avhich  represents 
the  amount  of  difference  in  inches  between  the  real  and  apparent 
shortening  is  followed  until  it  intersects  the  line  which  represents 
the  pelvic  breadth,  the  angle  of  deformity  will  be  found  in 
degrees  where  they  meet.  If  the  praetical  shortening  is  greater 
than  the  real  shortening,  the  diseased  leg  is  adducted  ;  if  less  than 
real  shortening,  it  is  abducted.  Take  an  example  :  Length 
(from  anterior  superior  spine)  of  right  leg,  23  ;  left  leg,  22J  ; 
length  (from  umbilicus)  of  right  leg,  25 ;  left  leg,  23  ;  real 
shortening,  |  inch ;  apparent  shortening,  2  inches ;  difference 
between  real  and  practical  shortening,  1|  inches ;  pelvic  meas- 
urement, 7  inches.     If  we  follow  the  line  for  1^  inches  until  it 


Fig.  194. 


A  C 

Kingsley's  method  of  estimating  flexion. 


intersects  the  line  for  pelvic  breadth  of  7  inches,  we  find  12°  to 
be  the  angular  deformity,  as  the  practical  shortening  is  greater 
than  the  real,  it  is  12°  of  adduction  of  the  left  leg.  If  apparent 
lengthening  is  present  its  amount  should  be  added  to  the  amount 
of  actual  shortening." 

If  flexion  is  present  the  degree  may  be  ascertained  by  raising 
the  flexed  limb  until  the  lumbar  spine  touches  the  table,  when  the 
angle  formed  by  the  thigh  with  the  body  may  be  measured  with 
the  goniometer  (Fig.  186),  or  its  degree  may  be  ascertained  by 
Kingsley's  table. 

"  The  patient  lies  upon  a  table  flat  on  his  back  and  the  surgeon 
flexes  the  diseased  leg,  raising  it  by  the  foot  until  the  lumbar 
vertebrae  touch  the  table,  showing  that  the  pelvis  is  in  the  correct 
position.     The  leg  is  then  held  for  a  minute  at  that  angle,  the 


318 


ORTHOPEDIC  SURGERY. 


knee  being  extended,  while  the  surgeon  measures  off  two  feet  on 
the  outside  of  the  leg  with  a  tape  measure,  one  end  of  which  is 
held  on  the  table  (so  that  the  tape  measure  follows  the  line  of 
the  leg)  [A  B).  From  this  point  on  the  leg  {B)  where  the  two 
feet  reaches  by  the  tape  measure  one  measures  perpendicularly 
to  the  table  {B  C),  and  the  number  of  inches  in  the  line  B  C  can 
be  read  as  degrees  of  flexion  of  the  thigh  by  consulting  Table  II. 
For  instance,  if  the  distance  between  the  point  on  the  leg  and  the 
table  is  12 J  inches  it  represents  31°  of  flexion  deformity  of  the 
thigh. 

Table  II.^ 


0. 5  inches. 

1° 

6. 5  inches. 

16° 

12. 5  inches.  31° 

18. 5  inches. 

50° 

1.0  " 

2 

7.0   " 

17 

13.0   * 

33 

19.0   " 

52 

1.5  " 

3 

7.5   " 

19 

13.5   • 

34 

19.5   " 

54 

2.0   =' 

4 

8.0   " 

20 

14.0   ' 

36 

20.0   " 

56 

2.5   " 

6 

8.5   " 

21 

14.5   ' 

37 

20.5   " 

58 

3.0   " 

7 

9.0   " 

22 

15.0   ' 

39 

21.0   " 

60 

3.5   " 

9 

9.5   " 

24 

15.5   ' 

40 

21.5   " 

63 

4.0   " 

10 

10.0  •' 

25 

16.0   ' 

42 

22.0   " 

67 

4.5   " 

11 

10.5   " 

27 

16.5   ' 

43 

22.5   " 

70 

5.0   '• 

12 

11.0   " 

28 

17.0   ' 

45 

23. 0   " 

75 

5.5   " 

14 

11.5   " 

29 

17.5   ' 

47 

23. 5   " 

80 

6.0   •' 

15 

12.0   " 

30 

18.0   ' 

48 

24.0   " 

90 

"  If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off 
twenty-four  inches  one  can  measure  twelve  inches ;  ascertain 
from  here  the  distance  to  the  surface  on  AAdiich  the  patient  is 
lying  in  a  perpendicular  line  in  the  same  way,  then  doubling  this 
distance  and  looking  in  the  table  as  before  the  amount  of  flexion 
is  found." 

Atrophy.  The  circumference  of  the  thighs,  the  knees,  and 
the  calves  is  then  measured  at  corresponding  points  to  test  for 
atrophy  or  for  other  irregularities  that  may  require  explanation. 
The  atrophy  of  joint  disease  affects  the  entire  limb,  and  it  is  an 
unfailing  symptom  except  in  the  earliest  stage  of  the  disease.  It 
might  be  concealed  in  the  thigh  by  a  deep  abscess,  but  it  would 
still  appear  in  the  calf. 

Local  Signs  of  Disease.  The  hip-joint  is  so  concealed  by  the 
overlying  tissues  that  the  local  sensitiveness  and  swelling  which 
usually  accompany  similar  disease  at  the  knee  and  ankle  are  often 
absent.  Firm  pressure,  before  or  behind  the  trochanter,  or  over 
the  head  of  the  femur  usually  causes  some  discomfort,  however. 
In  many  instances  a  peculiar  resistance  of  the  deeper  parts,  caused 
by  infiltration  of  the  tissues  that  cover  the  joint,  is  evident  on 
palpation  ;    and  swelling  about  the  joint  and  thigh,  caused  by 


1  G.  L.  Kingsley.    Boston  Medical  and  Surgical  Journal,  July  5,  1888. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  319 

effusion  or  by  deep  abscess,  is  not  unusual  when  patients  are  first 
brought  for  treatment.  Sensitiveness  of  the  skin  and  local  eleva- 
tion of  the  temperature  may  be  present  if  the  disease  is  acute, 
particularly  if  an  abscess  is  on  the  point  of  breaking  through  the 
skin. 

The  diagnosis  of  tuberculous  disease  of  the  hip,  except,  per- 
haps, in  the  stage  of  inception,  is  in  most  instances  evident 
on  a  systematic  examination,  such  as  has  been  outlined,  and 
it  is  probable  that  errors  are  due  rather  to  a  neglect  of  such 
examination  than  to  any  particular  obscurity  that  the  ordinary 
case  may  offer. 

Diagnosis.  Local  Irritation.  Strains  of  the  muscles  of  the 
thigh,  enlarged  glands  in  the  groin,  irritation  or  disease  of  the 
genitals  may,  in  infancy  or  early  childhood,  cause  persistent 
flexion  of  the  thigh  and  pain  on  motion.  Simple  muscular 
strains  quickly  recover,  while  the  inflamed  glands  and  other 
causes  of  local  irritation  are  usually  apparent  on  inspection. 

"  Growing  Pains."  So-called  growing  pain  is  probably  due  in 
many  instances  to  strain  of  the  muscles  or  to  injury  about  the 
hip ;  in  other  cases  it  may  be  explained  by  rheumatism. 

Local  Injury.  It  would  appear  that  injury,  often  of  a  trivial 
character,  may  cause  congestion  in  the  neighborhood  of  the 
epiphyseal  cartilage  of  the  head  of  the  femur  and  that  injury  of 
this  character  in  delicate  children  may  be  the  predisposing  cause 
of  tuberculous  disease.  Such  a  sensitive  condition  causes  a 
limp,  pain,  or  discomfort  on  overuse  and  restriction  of  motion. 
These  symptoms  may  last  a  few  days  or  a  few  weeks  ;  they 
may  disappear  and  recur  from  time  to  time,  and  they  can  only 
be  distinguished  from  those  of  incipient  disease  by  continued 
observation. 

Synovitis.  In  certain  cases  of  injury  synovial  eifusion  may  be 
present,  although  this  is  unusual. 

In  the  cases  in  which  the  functional  disturbance  is  caused  by 
local  irritation  or  by  slight  strain  the  symptoms  are  of  sudden 
onset  and  are  evidently  of  trivial  importance,  but  if  there  is  any 
doubt  as  to  the  diagnosis  the  hip  should  be  bandaged  and  the 
patient  should  remain  in  bed  or  at  rest  until  the  complete  subsid- 
ence of  the  symptoms  or  their  persistence  makes  the  diagnosis  clear. 

Anterior  Poliomyelitis.  Occasionally  anterior  poliomyelitis  may 
be  accompanied  by  pain  on  motion  in  the  affected  limb  before 
paralysis  is  apparent,  but  in  a  few  days  at  most  the  diagnosis  is 
evident. 


320  ORTHOPEDIC  SUBGEBY. 

Rheumatism.  Rheumatism  is  usually  of  sudden  onset.  It  is 
almost  always  migratory  in  character  and  it  is  accompanied  by 
fever.  If  it  were  confined  to  a  single  joint,  as  is  sometimes  the 
case  in  young  children,  and  if  the  history  were  obscure,  the  diag- 
nosis might  be  uncertain  for  a  time.  In  such  cases  appropriate 
remedies  should,  of  course,  be  employed. 

Scurvy.  This  is  also  an  affection  whose  symptoms  are  general 
in  character.  It  is,  therefore,  more  likely  to  be  confounded  with 
rheumatism  than  with  a  local  disease.  In  rare  instances  one 
joint  only  appears  to  be  involved,  but  this  is,  as  a  rule,  the  knee 
rather  than  the  hip.  Pain  on  motion  of  the  limbs,  in  an  infant 
artificially  fed,  always  suggests  scurvy. 

Infectious  Arthritis  and  Epiphysitis.  Mild  forms  of  infectious 
arthritis  may  follow  scarlet  fever,  diphtheria,  pneumonia,  and,  in 
a  more  severe  and  destructive  form,  typhoid  fever.  As  a  rule, 
however,  several  joints  are  involved,  and,  although  the  affection 
might  be  mistaken  for  rheumatism,  it  could  hardly  be  confounded 
with  local  tuberculous  disease. 

Infectious  arthritis  or  epiphysitis  of  the  hip-joint  is  not  un- 
common in  early  infancy.  It  is  of  sudden  onset,  accompanied  by 
high  fever  and  by  constitutiona  disturbance.  These  symptoms, 
together  with  the  local  heat  and  swelling,  caused  by  the  rapid 
formation  of  pus,  show  the  character  of  the  affection  and  indicate 
the  necessity  for  prompt  surgical  intervention. 

Gonorrhoeal  arthritis  is  a  form  of  joint  infection  that  in  adult 
age  may  resemble  somewhat  the  subacute  form  of  tuberculous  dis- 
ease. As  a  rule,  however,  it  is  of  sudden  onset  and  is  evidently 
associated  with  the  local  disease. 

Extra-articular  Disease.  Disease  in  the  neighborhood  of  the 
joint,  as  of  the  trochanter  or  of  the  tuberosity  of  the  ischium, 
may  cause  a  limp  and  pain  ;  in  most  instances  the  local  sen- 
sitiveness and  local  swelling  indicate  the  seat  of  the  disease,  while 
motion  of  the  joint  is  limited  only  in  the  directions  that  cause 
tension  on  the  sensitive  parts. 

Osteoarthritis  of  the  Hip.  Osteoarthritis  at  the  hip-joint  may  be 
mistaken  for  tuberculous  disease,  and  at  times  the  diagnosis  may  be 
obscure.  This  is,  however,  a  disease  of  adult  life,  aud  it  is  in  most 
instances  accompanied  by  other  evidences  of  a  general  affection. 
The  general  form  of  rheumatoid  arthritis  in  childhood  may  begin 
in  a  single  joint.  The  pain  may  be  severe,  and  there  may  be 
muscular  spasm  and  distortion  of  the  limb.  The  diagnosis  is 
usually  made  clear  by  the  successive  involvement  of  other  joints. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  321 

Pott's  Disease.  Disease  of  the  lumbar  region  of  the  spine  before 
the  stage  of  deformity,  when  the  pain  is  referred  to  the  lower 
extremities,  and  in  which  unilateral  psoas  contraction  causes 
a  limp,  is  often  mistaken  for  hip  disease,  although  the  dis- 
tinction between  them  is  very  clear.  Psoas  contraction  limits 
extension  only  ;  all  the  other  movements  of  the  limb  are  unre- 
strained. The  muscular  spasm,  of  Avhich  the  psoas  contrac- 
tion is  a  part,  is  a  spasm  of  the  muscles  of  the  spine  about  the 
seat  of  disease,  as  is  evident  on  examination.  Other  causes  of 
psoas  contraction  have  been  mentioned  in  the  consideration  of 
Pott's  disease.  In  exceptional  cases  active  disease  of  the  lower 
region  of  the  spine  in  young  children  may  set  up  spasm  of  the 
muscles  about  the  hip,  and  vice  versa,  so  that  it  may  be  impossible 
to  decide  at  the  first  examination  whether  the  irritation  is  in  the 
hip  or  in  the  spine  or  in  both. 

Sacro-iliac  Disease.  Disease  of  the  sacro-iliac  junction  is  very 
uncommon  in  childhood.  The  symptoms  and  the  attitude 
resemble  sciatica  rather  than  hip  disease.  There  is  local  pain  at 
the  seat  of  disease  upon  lateral  pressure  on  the  pelvis,  and  if  the 
pelvis  be  fixed  the  motion  at  the  hip-joint  will  be  found  to  be 
free  and  painless. 

Disease  of  the  Bursse  about  the  Joint.  Inflammation  of  the 
bursse  about  the  hip  may  cause  local  swelling  and  sensitiveness, 
a  limp  and  limitation  of  motion  in  certain  directions,  but  the 
characteristic  muscular  spasm  of  hip  disease  is  absent.  Iliopsoas 
bursitis  forms  a  fluctuating  swelling  in  Scarpa's  space,  gluteal 
bursitis  a  localized  swelling  of  the  buttock. 

Coxa  Vara.  Depression  of  the  neck  of  the  femur  is  a  simple 
deformity  in  which  disease  is  absent.  It  causes  a  limp  and  more 
or  less  discomfort,  but  the  character  of  the  deformity,  shown  by 
the  actual  shortening  and  by  the  elevation  and  prominence  of 
the  trochanter  distinguishes  it  from  hip  disease,  in  which  these 
are  late  symptoms.  In  coxa  vara  there  is  unequal  limitation  of 
motion,  abduction,  flexion,  and  inward  rotation  being  somewhat 
restricted,  while  extension,  the  first  motion  limited  in  hip  disease, 
is  as  a  rule  not  affected. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood  or  Traumatic 
Coxa  Vara.  Fracture  of  the  neck  of  the  femur  in  childhood  is 
often  of  what  may  be  termed  the  green-stick  variety,  a  depression 
of  the  neck  of  the  femur  without  actual  separation  of  the  frag- 
ments ;  and  in  many  instances  the  patients  are  able  to  walk  about 
within  a  short  time  after  the  accident.     In  such  cases  the  limp 

21 


322  ORTHOPEDIC  8UR0EBY. 

and  discomfort,  attended  during  the  stage  of  repair  by  a  certain 
degree  of  muscular  spasm,  are  often  mistaken  for  the  symptoms 
of  disease.  The  history  of  the  accident  followed  by  immediate 
disability,  the  shortening  and  the  elevation  of  the  trochanter 
are  usually  sufficient  to  exclude  disease.  In  doubtful  cases  the 
X-ray  may  be  required  to  establish  the  diagnosis. 

Congenital  Dislocation  of  the  Hip.  Congenital  dislocation  of 
the  hip  causes  a  limp,  but  it  is  a  limp  that  has  existed  since  the 
child  l3egan  to  walk  and  that  is  unaccompanied  by  the  symptoms 
of  disease.  The  nature  of  the  disability  should  be  apparent  on 
examination. 

Hysterical  Joint.  In  hysterical  subjects  a  limp,  apparent  pain, 
and  distortion  of  the  limb,  often  following  slight  injury,  may 
simulate  disease.  Hysteria  is  very  uncommon  at  the  period  of 
life  in  which  tuberculous  disease  is  most  frequent.  Patients 
suffering  from  hysterical  joints  usually  present  other  symptoms 
of  hysteria ;  the  characteristic  signs  of  disease,  muscular  spasm 
and  atrophy,  are  absent,  while  the  apparent  discomfort  and  the 
voluntary  distortion  are  quite  out  of  proportion  to  the  physical 
evidences  of  injury. 

The  X-ray  in  Diagnosis.  Roentgen  pictures  are  of  far  more 
value  in  demonstrating  deformity  than  in  establishing  early  diag- 
nosis of  disease,  especially  at  the  hip  in  early  childhood,  when  so 
large  a  part  of  the  extremity  of  the  femur  is  cartilaginous.  The 
pictures  are  of  value,  however,  in  showing  the  destructive  effect 
of  the  disease  on  the  head  of  the  femur  or  acetabulum,  and  thus 
giving  one  a  clearer  conception  of  the  actual  condition  of  the  joint 
than  would  be  possible  otherwise  (Fig.  192).  In  older  subjects 
it  may  be  possible  to  demonstrate  the  presence  of  disease  in  the 
interior  of  the  bone  by  this  means,  but  in  any  event  Roentgen 
pictures  are  of  value  only  when  interpreted  by  knowledge  of  the 
physical  signs. 

Method  of  Recording  a  Case.  The  record  should  contain 
the  general  history  of  the  patient  together  with  an  account  of  the 
more  important  symptoms,  and  of  the  treatment  that  may  have 
been  employed.  The  physical  examination  should  include  the 
weight  and  height  for  comparison  with  the  normal  standard,  and 
as  a  basis  on  which  to  judge  the  future  progress  of  the  case. 
Then  follows  a  brief  description  of  the  gait  and  attitude,  of  the 
character  of  the  distortion,  if  it  be  present,  and  of  the  changes 
from  the  normal  contour.  If  restriction  of  motion  is  present, 
its  causes  are  stated  if  possible ;  whether,  for  example,  it  is  due 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  323 

to  simple  muscular  spasm  or  in  part  to  adhesions  and  contrac- 
tions. 

The  presence  or  absence  of  heat  and  swelling,  of  abscesses, 
sinuses,  and  the  like  is  indicated.  If  there  is  actual  shortening 
of  the  limb  its  causes  and  distribution  should  be  stated ;  whether 
it  is  the  result  of  simple  retardation  of  growth  or  of  elevation  of 
the  trochanter,  as  may  be  ascertained  by  N6laton's  line  and  by 
Bryant's  triangle. 

If  the  elevation  is  due  in  great  part  to  the  enlargement  of 
the  acetabulum,  while  the  upper  extremity  of  the  femur  remains 
fairly  normal  in  shape,  the  jiroj action  of  the  trochanter  is 
more  noticeable,  and  the  distortion  of  the  limb  in  adduction  is 
greater,  than  when  the  elevation  is  the  result  of  destruction 
of  the  head  of  the  bone.  In  this  class  of  cases  Roentgen 
pictures  are  of  service  in  showing  the  actual  condition  of  the 
joint  (Fig.  193). 

A  condensed  account  of  the  more  important  points  in  the 
physical  examination  may  be  presented  by  the  formula  used  at 
the  Hospital  for  Ruptured  and  CrijDpled,  as  follows:  R.A. — 
R.U.— R.T.— R.K.— R.C.— A.G.E.— A.G.F.— A.S.P.— L.A. 
— L.U.— L.  T.— L.K.— L.C. 

"  A  "  indicates  the  distance  from  the  anterior  superior  spines 
to  the  internal  malleoli. 

"  U,"  from  the  umbilicus  to  the  same  points. 

cc  x^^'  "  K/'  and  "  C,"  the  circumferences  of  the  limb  at  the 
thighs,  knees,  and  calves. 

"  A.G.E."  indicates  the  augle  of  greatest  extension. 

"■  A.G.F.,"  the  angle  of  greatest  flexion.  Thus  the  restriction 
of  the  range  of  anteroposterior  motion  at  the  hip  is  shown  by 
these  measurements. 

"  A.S.P."  is  the  transverse  diameter  of  the  pelvis  between  the 
anterior  superior  spines,  the  measurement  required  in  Lovett's 
table  for  ascertaining  the  degree  of  lateral  distortion. 

If,  for  example,  the  record  read  : 

R.A.  18i— R.U.  20  — R.T.ll  — R.K.  8|— R.C.  7|-A.G.E.  150— A.S.P.  7 
L.A.  18.1-L.U.  211-L.T.lOl— L.K.  8]— L.C.  71— A.G.F.     90 

it  would  show  at  a  glance  that  there  was  no  real  shortening, 
that  the  limb  was  abducted  because  there  is  one  and  a  quarter 
inches  of  apparent  lengthening,  according  to  the  table,  the  equiv- 
alent of  10  degrees  of  abduction.  It  would  show  that  there  was 
permanent  flexion  of  30  degrees  and  a  range  of  motion  between 


324 


ORTHOPEDIC  SURGERY. 


the  limits  of  flexion   and  extension  of  60  degrees,  as  compared 
with  the  normal  of  about  130  degrees. 

The  following  details  of  the  one  thousand  cases  of  hip  disease 
investigated  for  me  by  Ashley  are  of  interest  as  illustrating  the 
character  of  the  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled  : 


The  Duration  or  Disease  when  Treatment  was  Begun. 


Three  months  or  less 
Three  to  six  months 
Six  months  to  one  year 
One  year     . 
Two  years  . 
Three  years 


396 
170 


124 


29 


Four  years .... 

21 

Five  years  .... 

17 

From  five  to  ten  years 

35 

From  ten  to  forty  years   . 

16 

Not  stated  .       .       .    •    . 

37 

1000 


The  Degree  of  Deformity  Present  on  First  Examination. 


No  deformity     . 

130 

55  degrees  of  flexion 

10 

5  degrees  of  flexion 

44 

60       "       "       "      . 

26 

10       "       "       "      . 

89 

65       " 

8 

15       ' 

69 

70 

22 

20       " 

118 

75        "        "        " 

2 

25        

32 

SO 

11 

30 

135 

85 

1 

35 

56 

90 

12 

40        

70 

More  than  90     . 

1 

45 

41 

Not  stated  . 

55 

50 

68 

1000 


Eestriction  of  Motion  at  First  Examination. 

Normal  motion 30 

A  range  of  motion  through  105  degrees 14 

65 

49 

95 

67 

112 

95 

157 


90 

75 

60 

45 

30 

15 

5 

No  motion 147 

Not  stated 169 


Attitude  of  the  Limb  at  First  Examination. 

Flexion  to  a  greater  or  less  degree 814 

No  flexion 130 

Not  stated     .       .       .       .      , _56 

1000 

Other  Distortions  Recorbed. 

Abduction 254 

Adduction 167 

External  rotation 166 

Internal        "              58 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  325 

Actual  Shortening  when  Treatment  was  Begun. 

1/  inch 129  ly^  inches 5 

^     " 143  21^  " 5 

K     " 22  23^  " 2 

1  " 51  3  " 2 

1^  inches 9  Sj^  " 2 

1%     " 16  3^  " 2 

l?i     " 6  9J^  " 1 

2  " 21                                                                        

416 

Shortening  absent  or  not  stated  in 584 

Abscess  was  present  in 105 

Treatment.  The  principles  that  should  govern  the  treatment 
of  a  disease  are  best  indicated  by  the  study  of  cases  that  have 
received  no  treatment,  and  that  show,  therefore,  the  natural  his- 
tory of  the  affection. 

A  characteristic  case  of  tuberculous  disease  of  the  hip-joint 
begins  insidiously.  It  causes  a  slight  limp  and  at  times  discom- 
fort and  pain.  In  the  early  stage  of  the  disease  there  is  slight 
flexion  of  the  limb,  usually  combined  with  abduction,  the  instinc- 
tive assumption  of  the  attitude  of  rest.  As  the  disease  progresses 
the  limb  becomes  less  capable  of  performing  its  proper  function  ; 
the  range  of  painless  motion  becomes  more  and  more  restricted, 
and  the  attitude  changes  to  one  of  increased  flexion  and  adduction, 
the  attitude  in  which  the  limb  is  best  protected  from  injury  and 
in  which  it  is  least  capable  of  performing  its  share  of  normal 
work.  Pain  is  more  constant,  abscess  is  often  present,  and  the 
constitutional  effects  of  a  depressing  disease  may  be  apparent. 
This  progression  of  symptoms  and  attitudes  is  so  fairly  constant 
that  hip  disease  was  in  former  times  often  divided  into  stages  corre- 
sponding to  these  early  and  later  manifestations  of  its  effects.  When 
the  limb  has  reached  the  position  of  greatest  protection,  when  mo- 
tion which  at  first  was  limited  only  by  the  involuntary  spasm  of 
the  muscles  that  are  now  atrophied,  is  restricted  by  adhesions  and 
contractions,  pain  often  ceases  to  be  a  troublesome  symptom,  the 
general  health  improves,  and  effective  repair  begins.  During 
the  progressive  stage  erosion  of  the  opposing  surfaces  of  the  joint 
has  advanced,  always  more  rapidly  at  the  points  of  mutual 
pressure  and  friction,  the  upper  and  inner  surface  of  the  head  of 
the  femur  and  the  upper  margin  of  the  acetabulum,  and  here  the 
disease  remains  active  while  repair  progresses  at  the  points  which 
have  been  relieved  from  irritation.  Thus  in  many  instances  the 
upper  margin  of  the  acetabulum  is  destroyed  and  a  subluxation 
of  the  femur  takes  place  (Fig.  181),  a  displacement  favored  by 


326  ORTHOPEDIC  SURGERY. 

the  attitude  of  flexion  and  adduction,  and  induced  by  muscular 
spasm  and  by  pressure  upon  the  limb.  In  some  instances  there 
is  complete  displacement,  and  when  the  diseased  parts  are  thus 
separated  from  one  another  by  this  form  of  pathological  dislo- 
cation relief  of  symptoms  and  practical  recovery  may  quickly 
follow,  although  sinuses  leading  to  areas  of  local  disease  or  to 
fragments  of  necrosed  bone  may  persist  for  many  years. 

Nature's  cure  of  hip  disease  implies  recovery  with  a  shortened 
and  distorted  limb,  a  final  result  which  is  common  enough  even 
when  treatment  has  been  employed  to  explain  the  popular  con- 
ception of  what  hip  disease  entails  (Fig.  190). 

As  has  been  stated,  it  was  customary  in  former  years,  when 
treatment  was  neglected  or  less  efficient  than  at  the  present  time, 
to  speak  of  a  first,  second,  and  third  stage  of  hip  disease,  corre- 
sponding to  the  character  of  the  deformity,  but  early  or  later 
stage  as  used  by  the  writer  refers  to  the  inception  and  progression 
of  the  local  pathological  process,  not  to  the  distortion  of  the  limb. 

There  are  many  cases  of  hip  disease  in  which  the  primary  focus 
in  the  head  of  the  bone  is  so  limited  in  extent  that  perfect  func- 
tional cure  may  result  under  any  form  of  treatment,  or  non-treat- 
ment even.  And  there  are  others  in  which  the  disease  is  of  such 
a  desfcractive  character  that  the  result  must  be  disastrous  in  spite 
of  treatment.  But  there  can  be  no  doubt  that  by  early  diagnosis 
and  by  efficient  protection  a  vast  amount  of  suffering  may  be 
prevented,  that  useful  function  may  be  preserved,  which  would 
otherwise  have  been  lost. 

The  object  of  treatment  is  to  prevent  the  symptoms  and  the 
effects  of  the  disease  that  have  been  outlined  as  characteristic  of 
the  untreated  cases.  To  relieve  the  pain  that  depresses  the 
vitality  of  the  patient.  To  relieve  the  muscular  spasm  that 
induces  distortion  of  the  limb,  and  that  stimulates  the  activity 
of  the  destructive  process  by  increasing  the  pressure  and  friction 
of  the  diseased  surfaces  of  the  opposing  bones.  To  correct  and 
to  prevent  deformity  and  to  prevent,  as  far  as  may  be  by  lessen- 
ing the  pressure  and  by  restraining  motion,  the  upward  displace- 
ment of  the  femur  that  causes  irremediable  distortion. 

There  are  cases  in  which  radical  removal  of  the  diseased  parts 
may  be  indicated,  and  there  are  times  when  acute  symptoms  may 
require  absolute  rest  of  the  patient.  But  in  the  management  of 
a  chronic  tuberculous  disease,  throughout  the  period  of  years  that 
may  elapse  before  cure  is  accomplished,  the  primary  require- 
ments of  the  treatment  that  have  been  indicated  must  be  met,  as 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.         327 

far  as  may  be,  by  appliances  that  allow  exercise  in  the  open 
air. 

Mechanical  Treatment.  The  most  effective  treatment  of  a  dis- 
eased joint  is  that  which  assures  it  the  most  perfect  rest  and  pro- 
tection. If  the  disease  is  in  the  earliest  stage  and  confined  to 
the  interior  of  the  bone,  rest  offers  the  most  favorable  condition 
for  repair  and  for  preservation  of  the  joint.  If  the  disease  is 
further  advanced,  complete  relief  of  function  affords  an  oppor- 
tunity for  nature  to  check  its  progress  and  to  preserve,  it  may 
be,  a  part  of  the  joint  from  invasion.  If  the  joint  is  already 
involved,  rest  offers  the  best  opportunity  for  repair  by  preventing 
friction  that  stimulates  the  progress  of  the  disease  and  increases 
its  destructive  effects.  Whatever  checks  or  retards  the  progress 
of  the  disease  correspondingly  relieves  its  symptoms  and  prevents 
constitutional  depression  and  thus  preserves  the  vital  resist- 
ance, both  local  and  general,  upon  which  the  cure  of  the  disease 
ultimately  depends.  Rest  of  a  diseased  joint  of  the  lower  ex- 
tremity necessitates  splinting,  stilting,  and  traction. 

Splinting  naturally  signifies  the  fixation  that  may  be  attained 
by  the  application  of  a  splint,  extending  a  sufficient  distance  on 
either  side  of  the  part  to  be  fixed. 

Stilting — the  elevation  of  the  foot  from  the  ground  so  that 
jar  and  pressure  on  the  diseased  articulation  may  be  removed. 

Traction — a  sufficient  force  exerted  upon  the  limb  to  over- 
come and  to  control  the  spasmodic  action  of  the  muscles. 

The  knee-joint,  the  junction  of  two  levers  of  similar  size  and 
function,  may  be  easily  controlled  or  placed  at  rest  by  means  of 
apparatus.  But  the  hip-joint  is  a  ball-and-socket  joint  which 
allows  free  motion  in  many  directions,  and,  being  the  junction  of 
the  body  and  the  limb,  two  segments  of  different  size  and  func- 
tion, it  is  especially  difficult  to  control.  For  this  reason  as 
much  as  any  other,  perhaps,  the  treatment  of  hip  disease  has 
been  the  subject  of  controversy  for  many  years.  And  even  at 
the  present  time  one  can  hardly  describe  the  treatment  of  hip 
disease  adequately  without  contrasting  the  methods  of  treatment 
that  are  in  common  use. 

Such  an  exposition  should  begin  naturally  with  a  description 
of  what  has  long  been  known  as  the  American  treatment,  in 
which  traction  has  always  occupied  the  most  important  place. 

The  Traction  Hip  Splint.  The  traction  hip  splint  consists  of  a 
pelvic  band  and  an  upright.  The  pelvic  band  is  made  of  sheet 
steel  about  an  eighth  of  an  inch  in  thickness  and  one  and  one- 


328 


ORTHOPEDIC    SURGERY. 


eighth  inches  in  width,  sufficiently  strong  to  support  the  weight 
of  the  body  without  yielding,  bent  into  a  U-shape  to  conform  to 
the  pelvis,  but  wide  enough  ^to  cause  no  anteroposterior  pressure. 
As  Taylor  puts  it,  there  should ^be  room  enough  for  the  pelvis  to 
move  freely  in  it.  This  band  embraces  about  three-quarters  of 
the  pelvis  at  a  point  just  above  the  trochanter.  It  is  covered 
with  leather,  and  is  provided  with  a  strap  to  complete  the  cir- 
cumference. Upon  the  pelvic  band  four  buckles  are  placed  for 
the  attachment  of  the  perineal  bands.     The  two  buckles  on  the 


Fig.  195. 


Fig.  196. 


Fig.  197. 


The  traction  hip  splint,  with  overlapping  upright  and  windlass,  used  at  the  Boston 
Children's  Hospital.    (Bradford  and  Lovett.) 

front  band  are  placed  directly  above  the  attachments  of  the 
adductor  muscles,  on  either  side  of  the  genitals.  Behind,  the 
buckles  are  placed  much  farther  apart,  somewhat  to  the  outer 
side  of  each  ischial  tuberosity,  upon  which,  in  great  part,  the 
weight  of  the  body  is  to  be  supported.  The  pelvic  band  is 
bolted  firmly  to  the  upright  at  a  slight  inclination,  correspond- 
ing to  the  inclination  of  the  pelvis.  The  upright  extends  from 
the  top  of  the  trochanter  to  two  or  more  inches  below  the  sole  of 
the  foot.     It  may  be  made  in  one  piece  or  in  two  sections  over- 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  329 

lapped  and  attached  to  one  another  by  screws,  to  allow  for 
adjustment  (Fig.  196).  It  is  turned  inward  at  a  right  angle 
below  the  foot  and  is  shod  with  leather  or  rubber.  The  foot- 
piece  may  be  provided  with  a  windlass  (Fig.  195),  or  the  traction 
may  be  made  by  simple  straps  attached  on  either  side  (Fig.  201). 
At  about  the  middle  of  the  upright  is  placed  a  support  of  light 
steel,  which  is  provided  with  a  broad  leather  strap  for  the  pur- 
pose of  fixing  the  thigh  to  the  brace  and  supporting  the  knee.  In 
some  braces  a  second  similar  support  is  placed  at  the  upper  part 
of  the  stem  ;  in  others  the  knee  is  supported  only  by  a  broad 
leather  pad  which  covers  its  inner  surface  and  is  attached  to  a 
cross-piece  on  the  upright  by  straps,  as  in  the  Taylor  brace.  In 
the  Taylor  brace,  which  has  served  as  a  model  for  all  similar 
appliances,  the  upright  is  a  steel  tube  into  which  slides  a  rod, 
supporting  the  foot  part  of  the  brace,  the  two  parts  being  joined 
with  a  rack-and-pinion  attachment  and  lock,  so  that  the  brace 
may  be  lengthened  or  shortened  by  means  of  a  key  (Fig.  200). 

Traction  Straps.  Traction  upon  tlie  limb  is  made  by  adhesive 
plaster,  preferably  that  known  as  moleskin  (yellow)  plaster,  which 
is  far  less  irritating  to  the  skin  than  rubber  plaster. 

These  plasters  should  be  cut  into  a  shape  corresponding  to  the 
lateral  aspect  of  the  thigh  and  leg,  thus  :  wide  above  and  narrow 
below,  reaching  from  the  trochanter  on  the  outer,  and  from  the 
pubes  on  the  inner  side,  to  the  malleoli  (Fig.  221).  The  lower 
ends  are  reinforced  by  a  second  layer  of  plaster  and  to  them 
buckles  are  attached.  The  plasters  are  then  applied  to  the  limb 
and  are  held  in  place  by  a  bandage  which  is  smoothly  applied 
and  then  sewed,  to  prevent  disarrangement.  The  object  of  the 
bandage  is  primarily  to  assure  the  adhesion  of  the  plaster  and 
secondarily  to  keep  it  clean.  It  can  be  replaced  by  a  properly 
fitted  covering  of  stockinette  or  by  a  stocking  leg. 

Another  method  of  applying  the  plaster,  designed  to  obtain 
a  better  hold  upon  the  limb,  is  that  devised  by  Taylor,  and 
described  by  him  as  follows  :  "  The  first  important  object  is  to 
seize  the  leg  in  such  a  manner  as  to  exert  against  it  an  unyield- 
ing force.  This  should  be  done  in  such  a  manner  as  will  not 
interfere  with  the  circulation,  nor  injure  the  knee,  by  unequal 
strain  either  below  or  above  it.  In  other  words,  the  whole  leg 
should  be  grasped  in  such  a  manner  that  the  knee  will  be 
supported.  It  may  be  done  as  follows  :  A  strip  of  adhesive 
plaster,  long  enough  to  reach  from  the  waist  to  the  foot,  and 
from  three  to  five  iiiclics  wide  at  the  upper  and  about  one-third 


330 


ORTHOPEDIC  SURGERY 


that  width  at  the  lower  end,  is  taken  and  cut  into  five  tails,  as 
shown  in  the  accompanying  illustration  (Fig.  198).  A  piece 
from  four  to  six  inches  long  is  cut  from  the  centre  tail  and  added 
to  the  lower  end  to  strengthen  it ;  and,  if  the  patient  be  strong, 
one  or  two  more  pieces  are  laid  on  the  same  place,  where  a  buckle 
is  attached.  Two  similar  straps  are  prepared,  one  for  the  inside 
and  one  for  the  outside  of  the  leg,  and  laid  against  the  lateral 


Fig.  198. 


Fig.  199. 


C.  F.  Taylor's  method  of  applying  adhesive  plaster. 


aspects  of  the  leg,  the  ends  with  the  buckles  beginning  about  two 
inches  above  the  internal  and  external  malleoli,  and  the  centre 
tails  reaching  the  entire  length  of  the  leg  and  thigh,  to  the  peri- 
neum inside  and  the  trochanter  on  the  outside.  The  lower  strips 
or  tails  are  then  wound  spirally  around  the  leg  to  the  pelvis  and 
afterward  the  other  two  pairs  of  tails,  which  are  cut  down  to  just 
above  the  knee,  are  also  wound  about  the  thigh  in  the  same 
manner.     When  completed  the  thigh  is  involved  in  a  network  of 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT. 


331 


Fig.  200. 


strips  of  adhesive  plaster,  which  act  equally  and  without  pressure 
on  the  whole  surface.  The  leg  has  about  one-fourth  of  the 
attachments,  and  the  thigh  three-fourths,  which  is  found  to  be  the 
right  proportion  to  protect  the  knee  equally  from  compression  or 
strain.  A  few  turns  of  the  roller  bandage  are  then  made  around 
the  ankle  just  under  the  lower  ends  of  the  straps,  which  serves 
as  a  protection  to  the  flesh  under  the 
buckles,  and  then  it  is  continued  over 
the  straps  on  the  whole  leg.  Thus 
prepared,  the  patient  is  ready  for  the 
splint"  (Fig.  199). 

At  the  Boston  Children's  Hospital 
the  lower  ends  of  the  adhesive  straps 
terminate  in  tapes  that  extend  be- 
low the  foot  for  attachment  to  the 
windlass,  which  is  used  with  the 
cheaper  form  of  brace. 

Perineal  Bands.  Perineal  bands 
are  made  by  covering  a  firm,  wide, 
unyielding  band  of  webbing  with 
several  folds  of  blanket  or  similar 
material  and  then  binding  it  smoothly 
with  canton  flannel.  These  are 
made  in  different  lengths  and  sizes, 
as  may  be  required. 

The  "High  Shoe."  The  best  and 
lightest  material  for  raising  the  shoe 
worn  on  the  sound  foot  to  corre- 
spond with  the  brace  is  cork,  and 
the  ordinary  thickness  is  two  and 
a  half  inches.  A  good  and  cheap 
substitute  may  be  made  of  light 
wood  provided  with  a  leather  sole,  and  in  certain  cases  a  patten 
of  metal  may  be  used. 

The  Application  of  the  Traction  Hip  Splint.  The  traction  brace 
is  applied  in  the  following  manner  : 

The  patient  lying  upon  his  back,  the  pelvic  band  is  first 
adjusted  and  is  strapped  about  the  body.  The  perineal  supports 
are  then  drawn  firmly  into  place  so  that  pressure  on  the  upright 
does  not  move  the  pelvic  band  from  its  proper  position  just 
above  the  trochanter.  The  brace  is  then  pushed  upward  against 
the  resistance  of  the  perineal  bands,  while  the  limb  is  at  the  same 


The  original  traction  hip  brace  pro- 
vided with  an  abduction  screw  and 
a  strap  to  regulate  the  inclination  of 
the  pelvic  band  on  the  upright. 


332 


ORTHOPEDIC  SURGERY. 


time  drawn  downward  and  is  fixed  by  attaching  the  straps  to  the 
buckles  at  the  ends  of  the  adhesive  plasters.  If  the  brace  is 
provided  with  a  windlass  or  ratchet,  further  traction  is  applied 
to  the  point  of  tolerance  by  means  of  the  key,  care  being  taken 
in  adjusting  the  brace  that  it  does  not  project  so  far  below  the 
foot  as  to  more  than  equal  the  extra  length  provided  by  the  high 


The  Judson  brace.    This  has  but  one  perineal  band,  and  the  upright  is  bolted  firmly  to 

the  pelvic  band. 


shoe  on  the  sound  side.  The  knee  band  is  then  adjusted  and  in 
many  instances  a  strap  is  placed  about  the  ankle  and  the  brace 
to  assure  greater  security.  The  shoe  is  then  put  on,  the  leg 
clothing  is  drawn  over  the  brace,  and  the  patient  is  allowed  to 
stand.  If  in  walking  the  patient  is  inclined  to  tilt  the  foot  down- 
ward and  to  bear  the  weight  on  the  toe,  a  strap  is  attached  to  the 
middle  of  the  foot-piece  and  fastened  to  a  buckle  on  the  heel  of 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


333 


the  shoe  with  sufficient  tension  to  hold  the  foot  in  the  horizontal 
position. 

By  means  of  this  brace  the  weight  is  borne  entirely  uf)on  the 
perineal  bands  ;  thus  the  joint  is  relieved  from  pressure  and  from 
jar.  The  perineal  bands  should  be  accurately  adjusted  to  pass 
upward  in  front,  parallel  to  one  another  on  either  side  of  the 
genitals,  in  order  to  avoid  pressure  on  the  inner  borders  of  the 
thighs ;  while  behind  they  turn  diagonally  outward  in  order  to 
pass  over  the  tuberosities,  which  are  best  adapted  for  weight 
bearing. 

In  the  original  Taylor  hip  brace  the  pelvic  band  is  bolted  to 
the  upright  in  a  manner  to  allow  anteroposterior  motion,  and  the 
inclination  of  the  pelvic  band  is  regulated  by  a  strap  attached 
to  the  upright  for  better  adjustment  (Fig.  200),  when  the  limb 


FiG.  202. 


The  reduction  of  flexion  by  means  of  the  traction  hip  splint.    (C.  F.  Taylor.) 

is  flexed  to  a  marked  degree.  This  brace  has  been  modified  by 
Taylor  by  shortening  and  changing  the  shape  of  the  pelvic  band 
for  the  use  of  but  one  perineal  support  (Fig.  231) ;  and  a  similar 
form  of  brace  is  used  by  Judson.  The  shortened  pelvic  band 
lessens  the  restraint  of  the  brace  upon  the  motion  of  the  limb, 
and  seems  to  offer  little  compensating  advantage. 

Before  the  traction  brace  is  used  in  ambulatory  treatment,  dis- 
tortion of  the  limb,  if  it  be  present,  should  be  reduced ;  or  if  the 
disease  be  particularly  acute  preliminary  rest  in  bed  until  the 
subsidence  of  the  symptoms  is  advisable. 

The  Reduction  of  Deformity  by  Means  of  the  Traction  Brace. 
The  patient  lies  in  bed  upon  a  firm  mattress  ;  the  distorted  limb 
is  then  raised  to  slightly  more  than  a  sufficient  angle  to  relax  the 
contracted  muscles  and  to  straighten  the  lumbar  lordosis ;  it  is 
then  abducted   or  adducted  if  necessary  until  the  level  of  the 


334  ORTHOPEDIC  SURGERY. 

pelvis  is  restored.  The  pelvic  band  is  made  to  couformi  to  this 
greater  relative  inclination  of  the  pelvis  by  lengthening  the  pos- 
terior strap  ;  the  brace  is  then  applied,  the  limb  being  held  in 
the  attitude  of  deformity  by  a  sling  or  support  (Fig.  202),  and 
as  much  traction  as  the  patient  can  tolerate  is  exerted  by  length- 
ening the  upright.  The  direct  traction  exerted  by  the  brace  may 
be  reinforced  by  means  of  a  cord  running  over  a  pulley  at  the 
foot  of  the  bed,  in  the  line  of  the  brace,  to  which  a  weight  of  ten 
or  more  pounds  (Fig.  203)  is  attached.  Thus  the  pressure  of 
the  perineal  bands  is  somewhat  lessened.  Efficient  traction  will 
quickly  reduce  recent  deformity  caused  by  muscular  contraction, 
and  as  this  is  lessened  the  position  of  the  limb  is  correspondingly 
changed  until  it  lies  extended  and  parallel  with  its  fellow.  If 
adduction  be  combined  with  flexion  the  perineal  band  on  the 
side  opposite  to  the  disease  is  tightened  from  time  to  time,  or  a 
direct  push  against  the  opposite  adductor  region  is  exerted  by 
means  of  a  bar  attached  to  the  brace  opposite  the  knee  (Fig. 
227).  In  ordinary  cases  the  deformity  may  be  reduced  by  this 
means  in  from  two  to  six  weeks. 

The  brace  should  be  worn  day  and  night.  The  perineal  bands 
may  be  loosened  at  times  to  allow  for  bathing  the  skin  with 
alcohol  and  for  powdering,  in  order  that  the  skin  may  be  kept 
dry ;  but  at  such  times,  if  the  disease  be  acute,  manual  traction 
should  be  made  until  the  brace  has  been  readjusted.  The  adhe- 
sive plasters,  if  of  moleskin,  may  often  remain  in  position  for 
three  months  or  longer.  When  they  are  removed  the  limb  is 
gently  bathed  with  alcohol.  Excoriations  are  unusual  unless 
rubber  plaster  is  used.  If  the  skin  is  abraded  the  part  should  be 
powdered  with  boracic  acid  and  protected  from  the  plaster  by  a 
layer  of  gauze. 

The  Kelative  Efficiency  of  the  Traction  Hip  Splint. 
In  analyzing  the  action  of  this  brace  it  is  evident  at  once  that  it 
is  thoroughly  effective  as  a  stilt.  It  is  effective  as  a  traction 
appliance,  in  the  sense  of  relieving  muscular  tension,  in  direct 
proportion  to  the  care  that  is  exercised  in  its  adjustment.  Trac- 
tion by  this  appliance  may  be  made  constant  and  effective,  even 
to  the  point  of  practical  fixation  while  the  patient  is  in  bed,  or 
when  crutches  are  used,  in  ambulatory  treatment.  But  when  the 
apparatus  is  used  as  a  walking  brace,  as  was  designed  by  its 
inventor,  constant  traction  is  not  exerted,  for  the  traction  straps 
alternately  relax  and  tighten  when  the  weight  of  the  body  falls 
upon  and  leaves  the  brace  in  walking.     When  the  brace  is  off 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


J5 


the  ground  the  joint  is  subjected  to  the  traction  that  the  brace 
exerts,  plus  its  weight,  as  contrasted  with  cessation  of  traction 
and  the  relief  from  the  weight  when  the  brace  supports  the  body 
at  the  alternate  step.  Thus  the  critics  of  the  brace  assert,  in 
somewhat  exaggerated  language,  that  it  exercises  a  pumping 
action  on  the  joint.  As  a  matter  of  fact,  the  observation  of 
patients  under  treatment  by  this  method  will  show  that  little 
actual  traction  is  exerted  in  the  ordinary  cases  ;  that  the  so-called 
traction  really  serves  principally  for  the  adjustment  of  the  brace, 
which  by  its  weight  exercises  a  certain  intermittent  traction  dur- 
ing locomotion.  The  hold  of  the  encircling  band  upon  the  pelvis 
assures  a  considerable  restriction  of  motion,  but  whatever  splint- 
ing action  it  may  have  depends  upon  the  degree  of  traction, 
which  is  never  effective  enough,  however,  to  prevent  a  certain 


Fig.  203. 


A  method  of  reducing  flexion  in  hip  disease.  The  brace  is  adjusted  to  the  angle  of 
deformity,  and  in  addition  to  the  direct  traction  of  the  apparatus  weights  are  attached  to 
the  brace  itself.  In  the  illustration  counter-traction,  by  means  of  perineal  bands  attached 
to  the  head  of  the  bed,  Is  shown. 

amount  of  motion.     This  point  is  illustrated  by  the  experiments 
of  Lovett,^  which  are  described  by  him  as  follows  : 

"  In  these  experiments  a  long  traction  splint  was  fitted  with  a 
self-registering  pencil  by  means  of  which  motion  at  the  hip-joint 
was  recorded  upon  the  skin  over  the  ilium.  This  was  done 
simply  by  carrying  the  shaft  up  so  that  it  held  the  pencil  perpen- 
dicularly to  the  skin.  A  splint  fitted  with  this  register  was 
applied  to  a  boy  with  normal  hip-joints,  and  traction  was  made 
up  to  the  usual  point,  being  about  three  pounds  and  a  half,  as 
registered  by  a  spring  balance  inserted  in  the  extension  straps. 
With  this  splint  on  the  boy  was  allowed  to  walk,  and  it  was 
found  that  the  hip  described  an  arc  of  thirty-five  degrees  of  joint 


li.  W.  Lovett.    New  York  Medical  Journal,  August  8, 1891. 


336  ORTHOPEDIC  SURGERY. 

motion.  In  sitting  clown  and  rising  an  arc  of  similar  extent  was 
described.  In  another  case  with  normal  hip-joints  the  motion 
was  found  greater,  and  the  register  showed  a  motion  of  forty 
degrees.  With  a  very  severe  amount  of  traction — so  much  so 
that  it  was  almost  unendurable — motion  of  fifteen  degrees  was 
recorded.  This  apparatus  was  first  tested  by  being  applied  to  a 
patient  with  anchylosis  of  the  hip,  when  it  was  found  that  no 
motion  was  recorded,  the  register  marking  by  a  dot.  These 
experiments  certainly  seem  to  show  that  to  a  healthy  hip-joint 
the  long  traction  splint  affords  very  imperfect  fixation,  and  it 
may  be  inferred  that  to  a  diseased  joint  equally  poor  support  is 
afforded." 

The  fact  must  be  borne  in  mind  that  the  traction  hip  splint 
was  not  intended  to  be  a  fixation  or  splinting  appliance.  On  the 
contrary,  Davis,  its  inventor ;  Taylor,  who  changed  it  into  a 
practicable  form,  and  Sayre,  who  further  modified  it,  each 
believed  that  motion,  except  when  the  joint  was  fixed  by  mus- 
cular spasm,  was  desirable. 

"  The  first  splint,  as  well  as  all  my  modifications,  admits  of 
free  motion  of  the  diseased  joint,  but  rigidly  excludes  all  friction 
of  the  diseased  surfaces  upon  one  another."^     (Davis.) 

"  Motion  without  friction  is  not  only  not  injurious,  but  it  is 
highly  beneficial."^     (Taylor.) 

"  For  the  ligaments  around  a  joint  will  become  fibrocartilag- 
inous or  even  osseous,  if  motion  is  denied  them,  particularly  if  a 
chronic  inflammation  is  going  on  within  the  joint  with  which 
they  are  connected. 

"  As  Dr.  Davis  is,  I  believe,  the  first  person  who  constructed 
an  instrument  embracing  these  important  advantages,  extension 
with  motion,  I  have  given  him  full  credit  for  the  same,"  etc.^ 
(Sayre. ) 

Motion  without  friction  in  this  sense  would  seem  to  imply  the 
actual  separation  of  the  femur  from  the  acetabulum,  or  distrac- 
tion as  distinct  from  traction. 

That  actual  distraction  is  possible  at  the  hip-joint  both  in 
health  and  disease  is  proved  by  the  experiments  of  Brackett*  and 
by  those  of  Bradford  and  Lovett.  These  experiments  show  that 
a  traction  force  from  ten  to  twenty  pounds  is  required  to  cause 

1  Davis.    Conservative  Surgery,  1867,  p.  214. 

-  Taylor.    The  Mechanical  Treatment  of  Disease  of  the  Hip-joint,  1873,  p.  15. 

3  Sayre.    Lectures  on  Orthopedic  Surgery,  1879,  p.  260. 

4  Brackett.    Transactions  American  Orthopedic  Association,  vol.  ii.    Bradford  and  Lovett, 
New  York  Medical  Journal,  August  4, 1894. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  337 

one-eighth  to  one-quarter  of  an  inch  of  actual  lengthening  of  the 
limb,  even  in  childhood.  It  is,  therefore,  to  say  the  least, 
unlikely  that  the  feeble  and  intermittent  traction  exerted  by  a 
hip  splint,  when  used  as  an  ambulatory  support,  can  be  sufficient 
to  separate  the  bones  from  one  another  and  thus  to  allow  motion 
without  friction  as  was  originally  claimed  for  this  apparatus.  In 
fact,  it  would  appear  that  the  claim  that  motion  was  of  positive 
benefit  to  the  diseased  joint  was  afterward  modified  by  the  up- 
holders of  this  method  of  treatment  to  a  negative  assertion  of  its 
harmlessness,  for  example  : 

"  If  the  disease  permits  a  certain  amount  of  motion  at  the 
affected  articulation,  motion  within  the  limits  set  by  nature  is 
not  harmful."^     (Shaffer.) 

This  statement  would  seem  to  imply  that  the  motion  per- 
mitted by  the  apparatus  might  be  varied  in  accordance  with  the 
degree  of  restriction  that  a  particular  case  presented,  provided  that 
this  motion  were  restricted  to  the  limit  set  by  nature.  In  actual 
practice,  however,  the  same  form  of  brace  is  applied,  and  with 
the  same  adjustment,  in  every  case  ;  or  as  it  is  stated  in  a  paper  on 
the  final  results  of  the  mechanical  treatment  by  this  apparatus  in 
dispensary  practice,  under  Shaffer's  direction  :  "  In  each  case 
reported  a  Taylor  traction  splint  was  applied  soon  after  the  first 
examination.  .  .  .  The  patient,  unless  recumbency  wa& 
necessary  to  overcome  a  malposition  of  the  limb  or  unless  the 
symptoms  were  so  acute  as  to  demand  rest,  was  allowed  almost 
unlimited  exercise  in  the  open  air."^  Yet  it  may  be  inferred 
from  the  report  of  the  final  results  in  these  cases  that  in  spite  of 
the  protection,  which,  in  many  instances,  must  have  restricted 
motion  within  the  limits  present  at  the  first  examination,  the 
range  of  motion  became  more  and  more  restricted,  for  in  16  of  35 
cases  reported  anchylosis  resulted,  and  in  7  others  the  motion  was 
less  than  ten  degrees.  Thus  in  74  per  cent,  of  the  cases  practical 
fixation  of  the  joint  was  found  on  the  final  examination. 

In  criticising  these  statistics  it  must  be  borne  in  mind  that  the 
patients  were  treated  under  all  the  disadvantages  of  dispensary 
practice,  and  that  the  final  usefulness  of  a  limb  is  by  no  means 
in  proportion  to  the  freedom  of  motion  that  may  be  preserved  ; 
still  with  these  reservations  it  can  hardly  be  claimed  that  the 
proportion  of    absolute  or  partial   anchylosis  would   have  been 

1  Shaffer.    Transactions  American  Orthopedic  Association,  vol.  ii.  p.  100. 

2  Shaffer  and  Lovett.    On  the  Ultimate  Results  of  the  Mechanical  Treatment  of  Hip-joint 
Disease.    New  York  Medical  Journal,  May  21,  1887. 

22 


338  OE  THOPEDIC  S  UR  GER  Y. 

greater  than  this  had  any  other  system  of  treatment  been  em- 
ployed. 

At  the  present  time  the  theory  that  motion  of  a  diseased  joint 
is  of  benefit,  or  even  that  it  is  harmless,  has  few  supporters  even 
among  those  who  use  the  traction  brace  exclusively.  On  the 
contrary,  the  motion  that  cannot  be  prevented  is  excused  because 
of  the  practical  efficiency  of  the  brace  and  because  it  is  believed 
that  no  more  effective  protection  can  be  attained  by  any  other 
method  of  ambulatory  treatment. 

In  all  acute  cases  a  period  of  rest  in  bed  with  traction  to  the 
point  of  actual  distraction  is  advised.  When  ambulation  is 
resumed  the  braced  limb  is  made  pendent  by  means  of  the  high 
shoe  and  crutches,  so  that  uninterrupted  traction  may  still  be 
exerted,  and  the  brace  is  only  used  as  a  supporting  appliance 
when  the  symptoms  indicate  that  the  disease  is  quiescent. 

Although  this  modification  of  treatment  was  not  followed  by 
Taylor,  still  in  his  later  writings  he  states  that  motion  is  of 
advantage  only  in  the  stage  of  recovery.  And  it  is  evident  that 
his  success  was  due  to  the  extreme  care  which  he  exercised  in  the 
supervision  of  the  patients,  and  in  adapting  treatment  to  the  vary- 
ing phases  of  the  disease  rather  than  to  any  theory  that  he  may 
have  advocated.^ 

As  has  been  stated,  treatment  by  the  long  traction  brace,  by 
means  of  which  motion  without  friction  was  at  one  time  claimed 
to  be  possible,  and  in  which  traction  is  the  distinctive  feature,  is 
sometimes  called  "  The  American  Treatment  of  Hip  Disease." 
In  this  sense  the  direct  splinting  of  the  joint  without  traction,  by 
means  of  the  Thomas  brace,  might  be  called  in  distinction  "  The 
English  Treatment." 

The  Thomas  Treatment  of  Hip  Disease.  H.  O.  Thomas,^  of 
Liverpool,  writing  at  a  time  when  in  America  it  was  generally 
believed  that  motion  was  essential  to  the  well-being  of  a  diseased 
joint,  and  when  fixation  was  supposed  to  predispose  to,  or  to 
actually  induce,  anchylosis,  states  "  that  continuity  of  extension 
'per  se  is  not  a  remedy  in  hip-joint  disease  ;  in  its  application  it 
involves  unavoidably  a  fractional  degree  of  fixation  which  is  suffi- 
cient to  mask  the  evil  of  this  ridiculous  malpractice." 

The  conclusions  on  which  his  treatment  is  founded  are  these  : 
"  The  main  obstacle  to  the  cure  of  an  inflamed  joint  is  the  friction 

1  Boston  Medical  and  Surgical  Journal,  March  6,  1879. 

2  Diseases  of  the  Hip.  Knee,  and  Ankle-Joints,  Treated  by  a  New  and  Effective  Method, 
1875,  p.  10. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


and  pressure  of  its  surfaces  ;  consequently  the  attainment  of  rest, 
that  is  of  immobility  of  the  articulation,  ought  to  be  the  principle 
which  should  guide  the  treatment.  Pressure  and  concussion  are 
less  to  be  feared  than  friction.  Effectual  rest  can  only  be  ob- 
tained by  mechanical  treatment,  and  for  this  purpose  the  appli- 
ances which  I  here  recommend  are  effectual.  The  more  an 
inflamed  joint  is  moved  the  stiffer  does  it  become  ;  while  the 
more  effectually  it  is  fixed,  the  sooner  and  the  more  completely 
is  its  capability  of  movement  restored.  To  insure  permanency  of 
cure  the  control  should  be  maintamed  for  a  period  beyond  the 
time  when  resolution  has  taken  place.      This  prolonged  arrest  of 


Fig.  204. 


Fig.  205. 


The  Thomas  hip  splint,  covered  and  fitted  with  shoulder  straps. 
(Ridlon  and  Jones.) 


a  joint's  movements,  for  even  an  unnecessarily 
long  period,  I  have  never  found  to  do  harm." 

The  splint  used  by  Mr.  Thomas  to  carry  out 
these  principles  effectively  is  described  by  him 
substantially  as  follows  : 

A  flat  piece  of  malleable  iron,  three-quarters 
of  an  inch  wide  and  three-sixteenths  of  an  inch 
thick  for  children,  and  one  inch  by  one-quarter 
inch  for  adults,  long  enough  to  extend  from  the 
lower  angle  of  the  scapula  to  the  middle  of  the  calf,  forms  the 
upright.  This  is  fitted  to  the  body  of  the  patient,  passing  from 
the  lower  angle  of  the  scapula,  in  a  perpendicular  line,  down- 
ward, over  the  lumbar  region,  across  the  pelvis,  slightly  external, 
but  close  to  the  posterior  spinous  process  of  the  ilium  and  the 
])rominence  of  the  buttock,  along  the  course  of  the  sciatic  nerve 
to  a  point  slightly  external  to  the  calf  of  the  leg.  It  must  be 
carefully  modelled  to  this  track.     The  lumbar  portion  of  the 


The  splint  in  its  sim- 
plest form,  not  yet  pad- 
ded or  covered.  (Rid- 
lon.) 


340  OB THOPEDIG  SUBGEB  Y. 

upright  must  be  invariably  almost  a  plane  surface,  but  it  must 
be  twisted  slightly  on  its  long  axis  at  the  junction  of  the  upper 
and  middle  third,  so  that  the  anterior  surface  of  the  lower  part 
may  look  slightly  outward  to  correspond  to  the  contour  of  the 
buttock  and  thigh.  A  second  and  double  bend  is  made  in  the 
upright  at  the  point  where  it  passes  the  buttock,  so  that  the 
thigh  part  lies  on  a  slightly  higher  plane  than  the  body  part,  but 
parallel  with  it.  The  upright  is  then  provided  with  chest,  thigh, 
and  leg  bands  (Fig.  204). 

The  chest  band  is  of  hoop  iron  one  and  a  half  inches  in  width 
by  one-eighth  of  an  inch  in  thickness.  This  is  bent  into  an  oval 
to  correspond  with  the  shape  of  the  chest,  being  four  inches  less 
than  the  circumference  at  this  point  if  the  patient  is  an  adult, 
and  of  a  corresponding  size  for  a  child.  It  is  riveted  to  the 
upper  extremity  of  the  brace,  so  that  one-third  of  its  length  shall 
be  on  the  side  corresponding  to  the  diseased  joint  and  two- 
thirds  on  the  other.  The  thigh  band  and  leg  band  are  of 
similar  material,  three-quarters  by  one-eighth  of  an  inch  in 
size.  The  thigh  band,  in  length  equal  to  two-thirds  of  the 
circumference  of  the  thigh,  is  fastened  to  the  upright  at  a 
point  one  to  two  inches  below  the  buttock,  and  the  calf  band, 
equal  in  length  to  half  the  circumference  of  the  leg  at  the  calf, 
is  riveted  to  the  lower  extremity  of  the  brace.  Both  the  thigh 
and  leg  bands  are  attached  to  the  brace  at  points  slightly  to  the 
inner  side  of  the  centre,  so  that  the  outer  arm  of  each  band  is 
somewhat  longer  than  the  inner.  The  brace  is  padded  with  thin 
boiler  felt  and  is  covered  smoothly  with  basil  leather.  In  fitting 
the  brace  to  the  patient  the  long  part  of  the  chest  band  should  be 
made  to  hug  the  body  closely,  while  the  short  arm  should  be 
somewhat  away  from  it.  The  anterior  surface  of  the  thigh  part 
of  the  upright  should  have  a  perceptible  outward  twist  and 
should  be  somewhat  on  the  inner  side  of  the  popliteal  space. 
Thus  the  instrument  is  prevented  from  rotating  outward  and 
becoming  a  side  splint.  The  chest  band  is  closed  with  a  strap 
and  buckle  ;  it  is  suspended  by  shoulder  straps,  and  the  leg  between 
the  two  bands  is  attached  to  the  brace  by  means  of  a  flannel 
bandage.  Ridlon  states  that  in  practice  this  bandage  is  usually 
replaced  by  a  strip  of  basil  leather  passed  across  the  front  of  the 
limb  close  down  to  the  upper  border  of  the  patella,  thence  back- 
ward and  downward  to  the  stem  of  the  splint  and  pinned  to  the 
covering,  so  that  the  resistance  to  the  downward  working  of  the 
brace  is  borne  by  the  quadriceps  femoris  muscle.     The  ordinary 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


341 


shoulder  straps  may  be  replaced  by  a  single  bandage  looped  about 
the  upper  part  of  the  stem  (Fig.  206),  This  bandage  is  twisted 
for  a  length  of  about  six  inches,  then  separated,  the  ends  being 
carried  over  the  shoulders,  are  passed  through  holes  in  the  corre- 
sponding ends  of  the  chest  band,  where  they  are  knotted,  and 
finally  the  two  ends  are  tied  to  one  anotlier,  completing  the  cir- 
cumference of  the  chest  band. 

This  brace  is  fitted  by  the  surgeon  directly  to  the  patient's 
body  as  he  stands  erect.  If  the  limb  be  already  flexed  the  foot 
is  raised  by  blocks  until  the  lumbar  lordosis  is  straightened ;  the 


Fig.  206. 


Method  of  changing  the  line  of  pressure  on  the  skin  from  the  Thomas  hip  splint  by 
drawing  the  tissues  to  one  side.    (Ridlon  and  Jones.) 


brace  is  then  bent  to  fit  the  angle  of  deformity  and  is  applied  in 
the  usual  manner. 

The  brace  is  made  of  iron  because  it  is  less  elastic  than  steel, 
and  because  it  can  be  more  easily  twisted  by  wrenches.  It  must 
be  heavy  and  strong  in  order  to  splint  the  part  effectively,  and 
it  can  only  be  an  effective  splint  when  it  is  fixed  in  its  proper 
position  and  exercises  direct  pressure  upon  the  hip-joint.  In 
cases  in  which  the  brace  has  been  properly  employed  a  deep  fur- 
row should  appear  in  the  buttock  directly  over  the  neck  of  the 
femur.     Once  fitted  to  the  patient  it  is  changed  only  at  infrequent 


342 


OB  THOPEDIC  S UB QEB  Y. 


intervals  and  always  by  the  surgeon,  who  is  particularly  careful 
not  to  move  the  limb  during  the  active  stage  of  the  disease. 

The  double  Thomas  hip  splint  is  made  by  joining  two  single 
splints.  These  are  riveted  to  the  chest  band  above  and  are  con- 
nected at  the  lower  ends  by  a  crossbar,  unless  the  brace  is  to  be 
used  in  the  reduction  of  deformity.      Care  must  be  taken  that 

the  uprights  pass  to  the  outer 
side  and  not  directly  over  the 
posterior  superior  spines  of  the 
ilium. 

The  Reduction  of  Deformity  by 
the  Thomas  Method.  Preferably 
in  the  treatment  of  children  the 
double  brace  is  applied,  the  sound 
limb  being  fixed  in  the  extended 
position  wliile  the  flexed  limb  is 
supported  by  the  other  arm  of 
the  brace,  bent  to  the  angle  of 
deformity.  The  patient  is  con- 
fined to  the  bed  and,  as  the  mus- 
cular spasm  relaxes  under  the 
influence  of  enforced  rest,  the 
brace  is  straightened  slightly  by 
wrenches  from  time  to  time,  at  a 
point  opposite  the  joint,  to  con- 
form to  the  improved  position 
until  symmetry  is  restored.  In 
resistant  cases  this  gradual  re- 
laxation is  hastened  by  straight- 
ening the  brace  somewhat  at  in- 
tervals, to  which  the  attached 
limb  must  conform — a  gradual  forcible  reduction  of  deformity. 
According  to  Ridlon  and  Jones,  the  flexed  limb  is  often  forced 
to  conform  to  the  straight  brace  by  a  temporary  exaggeration  of 
the  lumbar  lordosis,  which  lessens  as  the  spasm  subsides  under 
treatment. 

The  treatment  is  divided  by  Mr.  Thomas  into  stages  : 

1.  A  preliminary  stage  of  rest  in  bed  for  the  reduction  of 
deformity  and  .to  allow  for  subsidence  of  acute  symptoms. 

2.  The  patient  is  then  allowed  to  go  about  ou  crutches  wearing 
an  iron  patten  at  least  four  inches  in  height  under  the  sound  foot 
(Fig.  207). 


Thomas  splint  applied  with  patten  and 
crutches. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


O/IO 


3.  When  all  symptoms  of  disease  have  subsided  and  when 
atrophy  of  the  muscles  is  marked  the  brace  may  be  removed  at 
night. 

4.  The  brace  is  finally  discarded,  but  the  patten  and  crutches 
are  still  used  in  walking. 

According  to  Ridlon^  the  records  of  Mr.  Thomas  show  the 
average  time  of  confinement  to  the  bed  to  be  twenty-two  weeks, 
and  the  average  duration  of  treatment  twenty-one  months. 

It  is  stated  by  Ridlon^  that  in  actual  practice  these  principles 
were  not  carried  out,  for  nearly  all  the  children  treated  under 
Thomas'  direction  at  the  time  his  observations  were  made  were 
walking  about  without  the  high  patten  and  crutches,  even  before 
the  deformity  had  been  overcome  and  while  muscular  spasm  and 
pain  persisted. 


Fig.  208. 


A  form  of  Thomas  brace  employed  in  the  treatment  of  infants.  The  pelvic  band  assures 
better  fixation.  The  screws  at  the  lower  extremity  are  arranged  to  permit  the  addition  ol  a 
foot-piece  for  traction. 

This  was,  however,  probably  an  exigency  of  practice  among 
the  poor,  and  at  all  events  it  is  in  line  with  Thomas'  contention 
that  pressure  and  concussions  are  less  harmful  than  friction. 

Modifications  of  the  Thomas  Brace.  Although  not  so  stated  in 
his  book,  Thomas  used  at  times  a  short  brace  extending  only  to 
the  lower  part  of  the  thigh,  thus  permitting  motion  at  the  knee. 
This  was  apparently  designed  as  a  convalescent  splint,  although 
its  use  was  not  restricted  to  that  class  of  cases.  In  certain  cases 
a  strip  of  iron,  "the  nurse,"  was  screwed  to  the  lower  extremity 
of  the  long  brace,  prolonging  it  beyond  the  foot  in  order  to  pre- 
vent the  patient  from  bearing  weight  upon  the  limb. 

The  Thomas  brace,  so  effective  in  preventing  and  overcoming 
flexion  deformity,  does  not  prevent  lateral  distortion.     In  fact, 


'  Transactions  American  Orthopedic  Association,  vol.  i.  p.  17. 

2  A  Report  of  Sixty-two  Cases  of  Hip  Disease  Observed  in  the  Practice  of  Hugh  Owen 
Thomas.    New  York  Medical  Journal,  October  4,  1890. 


344  ORTHOPEDIC  SURGERY. 

in  twenty-four  of  the  fifty-eight  patients  examined  by  Ridlon/ 
adduction  was  present ;  a  larger  proportion,  it  would  appear, 
than  would  be  found  in  a  like  number  of  cases  under  treatment 
with  the  traction  brace.  This  tendency  to  lateral  distortion  may 
be  guarded  against  by  placing  a  half  band  of  material  similar  to 

Fig.  209. 


The  long  plaster  spica  bandage.    The  doited  line  indicates  the  position  of  the  steel  support. 

the  chest  band  about  the  side  of  the  pelvis;  on  the  same  side 
for  adduction,  on  the  opposite  side  for  abduction  of  the  limb. 

The  Thomas  brace  has  a  great  advantage  over  other  appliances 
in  its  simplicity.     It  can  be  made  by  a  blacksmith,  but  it  must 

1  Loc.  cit. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT.  345 

be  fitted  by  the  surgeon.  This  fitting  requires  great  care.  In 
the  words  of  Mr.  Thomas,  "  the  fitting,  although  sometimes 
successful  in  one  visit,  may  at  other  times  occupy  many  days. 
The  surgeon  should  mould,  by  reducing  or  increasing  the  various 
curves,  until  the  instrument  ceases  to  tend  to  rotate,  and  at  none 
of  its  angles  irritates  the  patient."  He  concludes  in  a  general 
answer  to  the  criticisms  that  have  always  been  made  on  the 
difficulty  of  adjustment  of  the  appliance  as  follows:  "What  I 
can  invariably  do  must  be  possible  to  others." 

Treatment  by  the  Plaster  Bandage.  A  third  method  of  treat- 
ment is  that  by  means  of  the  plaster  bandage  without  crutches  or 
high  shoe.  This  is  simple  splinting  with  whatever  protection 
from  concussion  the  support  may  assure. 

This  treatment  might  be  called  the  German  method  if  the 
traction  hip  splint  and  the  Thomas  brace  are  to  be  designated  as 
American  and  English. 

As  used  in  the  surgical  clinic  at  Berlin,  the  plaster  bandage  is 
applied  from  the  line  of  the  nipples  to  include  the  foot,  the  limb 
being  fixed  in  an  attitude  of  slight  flexion,  abduction,  and  out- 
ward rotation.  As  a  rule,  the  first  bandage  is  applied  under 
anaesthesia  for  the  purpose  of  relaxing  the  muscular  contraction 
and  facilitating  the  application.  If  nutritive  shortening  of  the 
muscles  is  present,  sufficient  force  is  employed  to  overcome  the 
deformity.  The  spica  is  renewed  at  intervals  of  from  two  to  four 
months.  When  the  disease  is  cured  and  after  the  bandage  is 
finally  removed  traction  at  night  is  employed  for  a  time  by  means 
of  a  weight  attached  to  the  foot  to  prevent  the  tendency  to  dis- 
tortion. In  ambulatory  treatment  this  method  has  little  to 
recommend  it  except  expediency,  but  as  a  temporary  support  to 
be  used  before  the  application  of  a  suitable  brace  the  plaster  spica 
is  most  useful. 

When  properly  applied  it  is  an  admirable  support,  often  far  more 
comfortable  to  the  patient  than  any  brace,  and  it  is  at  times  an 
indispensable  form  of  dressing.  It  has  the  same  defects  as  the 
plaster  jacket,  and  it  may  receive  the  same  defence  that  its  most 
severe  critics  have  had  the  least  experience  in  its  use. 

Appijcatiox  of  the  Plaster  Spica  Bandage.  A  plaster 
bandage  to  assure  support  should  fit  perfectly,  consequently  it 
should  be  applied  as  closely  as  is  possible.  If  it  is  available  the 
trunk  and  the  limb  should  l)e  protected  by  a  close-fitting  covering 
of  shirting,  such  as  is  used  in  the  application  of  the  plaster 
jacket.     Those  parts  that  are  likely  to  be  subjected  to  pressure 


346 


OB THOPEDIC  SUBGEB  Y. 


— the  toes,  the  heel,  the  malleoli,  the  condyles  of  the  femur,  the 
sides  of  the  pelvis,  the  anterior  superior  spines,  and  the  thorax — 
should  be  suitably  protected  by  cotton  wadding,  which  may  be 
held  in  place  by  a  snugly  applied  canton-flannel  bandage.  The 
plaster  bandage  should  cover  the  lower  half  of  the  thorax,  and  it 
should  extend  to  the  ends  of  the  toes.  It  should  be  applied 
under  slight  extension  very  carefully  around  the  adductor  region 
and  the  buttock,  which  should  be  entirely  covered  and  supported. 
At  this  point,  in  the  line  in  which  the  bar  of  the  Thomas  hip 
splint  runs,  a  piece  of  splint  wood  or  a  strip  of  malleable  steel, 
long  enough  to  reach  from  the  middle  of  the  back  to  the  lower 
third  of  the  thigh,  should  be  incorporated  in  the  plaster  (Fig. 
207).      A  similar  piece  is  sometimes  placed  in  front  of  the  hip 


Fig.  210. 


■  H^H^H^^_!S  ^H 


A  modification  of  the  Lorenz  tiip  rest  used  in  the  application  of  the  plaster  spica  bandage. 
Another  form  is  illustrated  in  the  article  on  Congenital  Dislocation  of  the  Hip. 


and  another  beneath  the  knee,  the  points  at  which  the  bandage  is 
likely  to  break.  The  proper  anteroposterior  support  of  the  but- 
tock, consequently  of  the  hip-joint,  is  almost  invariably  neglected 
in  the  ordinary  application.  The  bandage  may  be  applied  in  the 
upright  posture  by  means  of  the  swing,  as  used  in  the  application 
of  the  plaster  jacket,  the  weight  being  supported  in  part  by  the 
sound  leg  while  the  other  is  pendent.  Or  it  may  be  applied  with 
the  patient  in  the  reclining  posture,  the  body  being  supported  by 
a  shoulder  rest,  and  the  pelvis  by  a  sacral  support.  The  arms 
are  then  drawn  above  the  head  to  increase  the  capacity  of  the 
thorax,  while  the  limbs  are  supported  by  an  assistant  (Fig.  213). 
In  the  more  recent  cases  deformity  may  be  practically  reduced 
at  the  second  application  of  the  bandage,  because  of  the  relaxation 
of  the  spasm  assured  by  the  rest  and  fixation ;  thus  it  is  particu- 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  347 

larly  useful  in  the  treatment  of  young  children  in  the  outdoor 
practice,  for  whom  hospital  care  would  otherwise  be  required. 

The  Short  or  Lorenz  Spica  Bandage.     The  short  spica 
bandage  is  used  as  routine  treatment  of  hip  disease  in  Lorenz's 

Fig.  211. 


The  Lorenz  spica,  showing  the  adjustment  to  the  pelvis.    la  this  case  it  is  extended  below 
the  Imee,  but  in  many  instances  motion  at  the  knee-joint  is  permitted. 

clinic  in  Vienna  unless  direct  weight  bearing  causes  pain.  It  is 
applied  in  the  manner  described  under  the  treatment  of  congenital 
dislocation  of  the  hip,  the  aim  being  to  fix  the  affected  limb  in 
an  attitude  of  slight  flexion  and  abduction,  the  primary  attitude 
of  hip  disease.      A  close-fitting  covering  of  shirting  is  drawn  over 


348 


ORTHOPEDIC  S  UB  GEB  Y. 


Fig.  212. 


the  limb  and  pelvis,  and  a  Avide  bandage  is  then  introduced 
between  the  skin  and  shirting  to  serve  as  a  "scratcher."  The 
bony  prominences  are  suitably  protected  by  cotton  or  sheet  wad- 
ding, and  the  bandages  are  then  applied,  being  drawn  closely 
about  the  pelvis  and  thigh,  so  that  the  movement  joint  may  be 
controlled.  The  upper  and  lower  extremities  of  the  bandage  are 
cut  away  as  illustrated,  and  the  shirting  is  then  drawn  over  the 
margins  of  the  plaster  and  sewed.  This  makes  a  smooth  cover- 
ing and  holds  the  padding  in  position.  If  the  bandage  is 
extended  below  the  knee  it  is  more  efficient.  As  an  adjunct  to 
mechanical  support  and  during  the  stage  of  recovery,  or  even  in 
the  treatment  of  cases  of  a  mild  type,  the  ban- 
dage is  very  satisfactory,  but  as  a  routine  treat- 
ment it  is  not  a  sufficient  protection.  It  should 
be  stated  that  in  the  treatment  of  the  more  acute 
cases  by  Lorenz  the  weight  of  the  body  is  re- 
moved by  a  prolongation  or  stirrup  of  sheet  steel 
which  projects  beyond  the  foot,  the  two  extremi- 
ties being  incorporated  in  either  side  of  the 
plaster  bandage  in  the  neighborhood  of  the  knee 
(Fig.  212).  In  the  better  class  of  cases  a  leather 
support  provided  with  a  steel  foot-plate  extending 
slightly  below  the  foot  and  a  joint  at  the  knee 
is  used.  The  short  spica  bandage  in  combination 
with  the  traction  hip  brace  (Fig.  220)  answers 
the  same  purpose  and  is  more  efficient  if  some- 
what more  cumbersome. 
sometimerused  \n  Immediate  Reduction  of  Deformity.  In  the  more 
the  treatment  of  the    rggigtant   cascs    au    anaesthetic    may  be  adminis- 

more  painful  cases.  •' 

This  is  incorporated    tcrcd.     If  the  deformity  is  due  simply  to  mus- 

in  the  plaster  ban-  i       t      i  i  i  i   •        i 

dage  above  the  cular  spasm  the  hmb  may  be  placed  in  the  proper 
SA'ife'foo?''"*^'  position  without  force,  but  if,  as  is  often  the  case 
when  the  distortion  is  of  long  standing,  it  is  caused 
in  part  by  shortening  of  the  muscles  and  fascia?,  a  certain  amount 
of  force  may  be  required. 

The  pelvis  should  be  fixed  and  the  force  should  be  applied  as 
far  as  possible  by  direct  extension  rather  than  by  leverage.  Sub- 
cutaneous division  of  the  contracted  tissues  about  the  anterior 
superior  spine  and  in  the  adductor  region  may  be  required.  In 
very  resistant  cases  the  reduction  of  deformity  by  this  method 
should  be  divided  into  several  operations.  Lorenz  reduces  the 
adduction  deformity  by  means  of  a  machine  that  exercises  direct 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


349 


traction  on  the  adducted  limb  while  the  sound  limb  is  pushed 
upward,  so  that  practically  no  leverage  is  exerted  on  the  joint/ 
In  cases  in  which  the  deformity  is  accompanied  by  abscess,  or 
when  the  joint  is  surrounded  by  infiltrated  tissues  and  by  sinuses 
this  treatment  should  not  be  employed.  In  fact,  in  certain  cases 
of  this  class,  especially  when  subluxation  is  present,  it  is  often 
advisable  to  disregard  the  deformity  that  cannot  be  reduced  by 
traction  until  the  disease  is  cured,  when  it  may  be  overcome  by 
osteotomy  of  the  femur. 


Fig.  213. 


The  hip  rest  iu  use.    The  patieut  presents  fixed  flexion  to  135  degrees,  and  fixed 
adduction  of  35  degrees. 

The  immediate  reduction  of  deformity,  properly  performed,  is 
free  from  danger ;  and  it  has  become  almost  the  routine  of  prac- 
tice in  the  indoor  department  of  the  Hospital  for  Ruptured  and 
Crippled.  The  great  advantage  of  placing  the  limb  in  the  proper 
position  and  fixing  it  for  weeks  or  months,  instead  of  employing 
this  time  for  the  gradual  reduction  of  the  deformity,  is,  of  course, 
self-evident. 


1  Lorenz.    SammhiiiK  l<lin.  Vor.,  206,  Leipzig,  March,  1898. 


350 


ORTHOPEDIC  S UR OER  Y. 


Three  methods  of  reduction  of  deformity  have  been  described  : 

1.  By  means  of  the  traction  brace. 

2.  By  means  of  the  Thomas  brace. 

3.  By  means  of  the  plaster  bandage,  with  or  without  anaes- 
thesia. 

A  fourth  method  is  that  by  means  of  the  weight  and  pulley. 
This  is  in  common  use  because  it  requires  no  special  apparatus. 

Fig.  214. 


: 


w 


Weight  extension  acting  as  leverage  iu  hip  disease.  P,  pulley  ;  W,  weight ;  F,  fulcrum. 
Marsh's  diagrams,  illustrating  the  advantage  of  traction  in  the  line  of  deformity,  in  order 
to  avoid  leverage.    (Howard  Marsh.) 

Reductiox  of  Deformity  by  the  Weight  axd  Pulley. 
The  traction  plasters  are  applied  to  the  limb  in  the  manner 
already  described  and  the  patient  is  placed  on  his  back  on  a 
narrow,  firm  mattress.  The  limb  is  raised  until  the  lumbar 
vertebrae  rest  upon  the  bed  and  it  is  then  moved  to  one  or  the 
other  side,  if  lateral  distortion  is  present,  until  the  level  of  the 
pelvis  is  restored.  In  this  position  the  limb  is  supported  on  a 
pillow,  or,  better,  on  the  adjustable  triangle  used  with  the  trac- 


FiG.  215. 


Posture  of  the  limb  in  hip  disease  in  which  extension  should  he  applied  in  order  to  avoid 
leverage.    P,  pulley  ;  W,  weight :  F,  fulcrum. 

tion  hip  splint  (Fig.  202).  A  pulley  is  then  attached  to  the 
foot  of  the  bed  in  a  prolongation  of  the  line  of  the  flexed  limb. 
The  wheel  may  be  screwed  to  the  top  of  a  narrow  board,  which 
may  be  raised  or  lowered  on  the  foot  of  the  bed  as  required. 
To  the  buckles  on  the  plaster  traction  straps  a  stirrup  carry- 
ing the  cord  is  attached.  This  stirrup  is  simply  a  spreader  of 
narrow,  thin  wood,  slightly  wider  than  the  foot,  provided  at 
either  end  with  straps  or  tapes,  its  purpose  being  to  prevent 
direct  pressure  on  the  malleoli    (Fig.   219).      By   means   of  a 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


351 


weight  suspended  at  the  foot  of  the  bed  traction  is  made  upon 
the  limb  to  the  extent  that  the  comfort  of  the  patient  will  per- 
mit. As  in  Buck's  system  of  extension,  the  foot  of  the  bed  is 
raised  to  increase  the  friction  of  the  body  and  thus  to  counteract 
the  traction  force,  but  in  the  treatment  of  children  this  is  ineffi- 
cient and  counter-traction  must  be  provided.  A  simple  method 
is  to  attach  two  perineal  bands,  as  described  in  connection  with 
the  traction  brace,  to  strong  tapes  that  pass  above  and  below  the 
patient's  body,  to  be  fixed  to  the  head  of  the  bed  at  a  suitable 
distance  from  one  another  ;  thus  the  pelvis  is  supported  by  pro- 
longed perineal  bands. 

In  order  to  assure  efficient  and  constant  traction  the  patient  must 
be  prevented  from  sitting  up.  For  this  purpose  a  swathe  about  the 
body  or  shoulder  straps  may  be  applied  and  attached  to  the  bed. 


Fig.  216. 


Extension  in  hip  disease.    Marsh's  method  of  fixing  the  patient  in  bed  with  shoulder 
straps  and  a  long  T-spUnt  on  the  sound  side.    (Howard  Marsh.) 


A  convenient  appliance  is  that  of  Marsh.  "  This  consists  of 
a  piece  of  webbing,  passing  across  the  front  of  the  chest  and 
ending  in  two  loops,  through  which  the  two  arms  are  passed, 
and  through  which  is  threaded  another  piece  of  stout  webbing, 
which  runs  transversely  across  the  surface  of  the  bed  under  the 
child's  shoulders,  and  is  fastened  at  its  two  ends  to  the  sides  of 
the  bedstead.  When  this  is  in  action  the  patient's  shoulders 
are  kept  flat  on  the  bed,  so  that  he  can  neither  sit  up  nor  turn 
on  his  side.  This  chest  band  does  not  cause  the  slightest  dis- 
comfort. It  is  not,  of  course,  fixed  tightly,  and  when  the  child 
finds  that  he  cannot  sit  up  he  makes  no  further  attempt  to  do 
so  ;  and  as  he  lies  flat  the  band  is  loose." 

It  is  often  of  advantage,  particularly  if  the  disease  is  active, 
to  use  some  form  of  apjiaratus  to  fix  the  patient  more  thoroughly. 


852 


ORTHOPEDIC  SURGERY. 


Marsh  uses  a  long  lateral  splint  of  thin  board  reaching  from  the 
axilla  to  a  crossbar  below  the  sole  of  the  foot.  To  this  the 
patient's  body  and  sound  limb  are  bandaged  (Fig.  216). 


Fig.  217. 


Traction  by  means  of  weight  and  pulley.    (R.  T.  Taylor.) 


Fig.  218. 


Method  of  fixing  the  patient  to  the  Bradford  frame  for  traction  in  hip  disease. 
(R.  T.  Taylor.) 

For  the  same  purpose  a  plaster  spica  bandage  or  a  Thomas 
splint  may  be  applied  on  the  sound  side,  but  a  more  convenient 
appliance  is  the  frame  of  gas-pipe  covered  with  canvas  that  has 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


353 


been  described  in  the  chapter  on  Pott's  disease.  Upon  this  frame 
the  patient  can  be  fixed,  the  limb  being  elevated  by  a  support 
attached  to  the  frame  or  independent  of  it  (Figs.  217  and  218). 
It  is  perhaps  needless  to  suggest  that  the  bedclothes  must  be  held 
from  the  elevated  limb  ;  in  fact,  that  the  patient  must  for  a  time 
be  enclosed  in  a  tent  of  bedclothes  if  the  deformity  is  extreme. 
At  first  the  traction  weight  must  not  be  great,  but  as  the  peri- 
neum becomes  accustomed  to  pressure  as  much  weight  as  can  be 
tolerated  is  used,  from  ten  to  twenty  pounds  being  the  average. 
This  may  be  reduced  at  night  and  increased  during  the  day. 
Great  care  must  be  taken  to  prevent  painful  pressure  on  the 
perineum  by  careful  adjustment  and  frequent  inspection  of  the 
perineal  bands. 


Fig.  219. 


Lateral  and  longitudinal  traction  in  hip  disease.    (Page.) 


If  the  frame  is  used  it  may  be  provided  with  a  windlass  at 
the  bottom  for  traction  and  with  an  arched  baud  of  metal  across 
the  pelvis  for  the  attachment  of  the  perineal  bands,  which  behind 
are  fastened  to  the  side  bars  at  a  higher  level.  Thus  the  frame 
may  be  made  an  independent  recumbent  splint  on  which  the 
patient  may  be  moved  about.  If,  however,  one  desires  to  exert 
traction  to  the  point  of  distraction,  the  weight  and  pulley  arrange- 
ment is  more  satisfactory  j  in  this  case  the  limb  should  be  placed 
in  an  attitude  of  slight  flexion  and  abduction,  so  that  the  femur 
may  bo  drawn  more  directly  from  the  acetabulum. 

Lateral  Traction.  Thus  far  longitudinal  traction  has  been  con- 
sidered, but  lateral  traction  or  traction  in  the  line  of  the  neck  of 
the  femur  deserves  some  consideration. 

23 


354  ORTHOPEDIC  SURGERY. 

Mr.  Thomas,  who  condemned  all  forms  of  traction  as  deceptive 
and  irrational,  and  especially  longitudinal  traction,  speaks  thus 
of  lateral  traction :  "  For  surely  if  relief  from  pressure  be 
required,  the  only  direction  in  which  this  is  possible  is  clearly  in 
the  axis  of  the  neck  of  the  femur.  Any  method  of  extension  in 
the  axis  of  the  body  merely  transfers  the  pressure  from  the  upper 
part  of  the  acetabulum  to  the  lower  quarter."^  This  contention 
is  purely  theoretical,  as  there  is  no  evidence  to  show  that  injurious 
pressure  is  ever  exerted  upon  this  part  of  the  acetabulum.  On 
the  contrary,  the  specimens  from  subjects  who  have  been  treated 
by  longitudinal  traction  in  recumbency  and  by  means  of  the  trac- 
tion hip  splint  almost  invariably  show  the  effect  of  pressure  upon 
the  upper  part  of  the  head  of  the  femur  and  upon  the  upper 
adjoining  margin  of  the  acetabulum.  Moreover,  the  neck  of  the 
femur  is  in  childhood  so  short  and  is  set  upon  the  shaft  at  so 
great  an  angle  that  longitudinal  traction,  if  the  limb  be  slightly 
abducted,  is,  practically  speaking,  in  the  line  of  the  neck ;  so 
that  even  from  the  theoretical  standpoint  the  question  of  injurious 
pressure  could  only  arise  in  the  treatment  of  adults.  The  advan- 
tage of  lateral  traction  in  the  treatment  of  hip  disease  has  been 
urged  with  great  persistency  by  A.  M.  Phelps^  since  1889,  and 
it  has  been  applied  as  a  routine  practice  in  ambulatory  treatment 
by  Blanchard,'^  of  Chicago,  since  1872. 

The  effect  of  lateral  traction  in  recumbency  has  been  carefully 
investigated  by  C.  G.  Page.*  His  conclusions  are  that  lateral 
traction  alone  is  of  no  benefit,  but  if  applied,  together  with  lon- 
gitudinal traction,  it  gives  great  relief  in  certain  acute  cases.  The 
longitudinal  traction  should  be  twice  as  great  as  the  lateral,  ten 
and  five  pounds  being  the  average  weights  employed  in  his 
experiments.     The  method  is  shown  in  the  illustration  (Fig.  219). 

The  Relative  Efficiency  of  Traction  and  Splinting 
("  Fixation"). 

In  considering  the  vexed  question  of  the  relative  merits  of 
splinting  and  traction  in  preventing  muscular  spasm  and  the  con- 
sequent intra-articular  pressure  which  causes  pain  and  increases 
the  destructive  effects  of  the  disease,  these  facts  must  be  borne 
in  mind. 

1  Loc.  cit.,  p.  10.  2  New  York  Medical  Record,  May  4,  1889. 

•5  Transactions  American  Orthopedic  Association,  vol.  vii. 

i  C.  G.  Page.    Boston  Medical  and  Surgical  Journal,  September  13,  ISgi. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT.  355 

The  more  acute  the  disease  the  less  ability  of  the  joint  to 
carry  out  its  proper  function,  which  is  motion.  The  greater  the 
motion  under  these  circumstances  the  more  intense  the  muscular 
spasm,  of  which  the  object  is  the  prevention  of  motion.  If 
it  were  possible,  therefore,  to  fix  the  joint  absolutely  there  should 
be  no  muscular  spasm,  although  the  tension  of  acute  disease 
within  the  bone,  or  of  its  products  within  the  joint,  might  cause 
pain. 

When  the  patient  is  fixed  in  the  recumbent  posture  it  is  pos- 
sible to  apply  a  sufficient  traction  uj)on  the  muscles  to  prevent 
the  spasmodic  contraction  that  causes  injurious  pressure,  and 
although  no  amount  of  traction  will  absolutely  prevent  motion, 
yet  with  the  support  that  the  bed  provides,  practically  speak- 
ing, complete  rest  may  be  assured.  Only  in  the  exceptional 
cases  in  which  tension  upon  congested  tissues  about  an  acutely 
inflamed  joint  is  intolerable  is  this  method  of  treatment  ineffi- 
cient. 

The  same  statement  is  true  of  a  properly  applied  spica  bandage 
or  Thomas  brace,  when  the  patient  is  recumbent,  that  it  assures 
practical  rest ;  thus  it  prevents  muscular  contraction,  relieves  the 
symptoms  and  promotes  repair,  although  it  cannot  be  claimed 
that  the  surfaces  of  the  opposing  bones  are  actually  separated 
from  one  another. 

But  what  is  true  when  the  patient  is  recumbent  is  not  true  in 
ambulatory  treatment.  The  traction  exerted  by  the  hip  splint 
even  when  the  limb  is  pendent  is  far  less  effective  than  in  recum- 
bency, and  when  it  is  used  as  a  walking  appliance,  for  which  it 
was  designed  and  for  which  it  is  j)ractically  always  employed, 
the  traction  is  intermittent  and  of  doubtful  efficiency.  The  same 
loss  in  efficiency,  although  in  far  less  degree,  occurs  in  all  forms 
of  fixative  apj)aratus  when  used  in  ambulation,  but  it  may  be 
stated  without  reserve  that  splinting  is  of  far  more  importance 
in  actual  practice  than  is  traction. 

The  Removal  of  Direct  Pressure.  "  Stilting."  Granting  that 
the  traction  brace  as  a  walking  appliance  is  relatively  inefficient 
in  preventing  motion,  and  that  motion  without  friction,  provided 
the  joint  surfaces  are  actually  involved,  is  impossible,  still  the 
traction  brace  is,  or  may  be,  at  all  times  an  effective  stilt  in  that 
it  protects  the  joint  from  concussion  and  pressure  by  removing 
the  foot  from  contact  with  the  ground. 

It  is  true  that  the  removal  of  direct  pressure  may  be  assured 
by  the  use  of  axillary  crutches,  but  in  Thomas'  practice  they 


356  ORTHOPEDIC  SUBGEBY. 

were  used  in  but  few  cases. ^  In  fact,  it  is  only  by  constant  super- 
vision that  the  use  of  crutches  can  be  enforced  upon  children  who 
no  longer  suffer  pain ;  and  as  it  is  practically  impossible  to  pre- 
vent the  patient  from  bearing  weight  upon  the  limb,  stilting  by 
this  means  is  relatively  inefficient. 

That  direct  pressure  is  one  of  the  causes  of  upward  displace- 
ment of  the  femur  may  be  inferred  from  the  statistics  of  Sasse 
and  Bruns,^  from  the  surgical  clinics  of  Berlin  and  Tubingen, 
where  the  routine  of  treatment  is  the  plaster  bandage  without  the 
high  shoe  or  crutches.  In  two-thirds  of  Sasse's  and  in  four-fifths 
of  Bruns'  cases  there  was  upward  displacement  of  the  trochanter. 
This  is  certainly  a  larger  proportion  than  would  be  found  in  a 
corresponding  class  of  patients  treated  by  efficient  stilting,  although 
statistics  on  this  point  from  American  sources  are  lacking. 

The  Practical  Combination  of  Traction.  Splinting  and  Stilting. 
Thus  far  the  methods  of  treatment  by  splinting  and  traction  have 
been  presented  as  if  they  were  necessarily  opposed  to  one  another 
in  principle,  and  as  if  the  theory  were  still  held  that  motion 
without  friction  is  possible  ;  and  as  if  it  were  believed  that  anchy- 
losis is  caused  by  fixation  and  is  prevented  by  the  motion  of  a 
diseased  joint.  At  the  present  time,  however,  it  is  generally 
recognized  that  the  principle  involved  in  both  methods  is  the 
same,  and  that  the  actual  merit  of  each  must  be  decided  by 
practical  experience  rather  than  by  argument.  The  true  test  of 
the  relative  value  of  a  routine  of  treatment  is  its  efficacy  in 
hospital  practice,  where  its  weak  points  cannot  be  supplemented 
by  the  careful  supervision  that  may  make  almost  any  treatment 
effective  that  carries  out  in  some  degree  the  proper  principle. 
This  test  is  all  the  more  necessary  because  the  great  majority  of 
cases  of  this  character  are  to  be  found  among  the  poor. 

From  this  point  of  view  the  writer's  experience  may  be  of 
interest.  His  early  training  was  entirely  in  the  traction  method, 
but  the  observation  of  a  large  number  of  cases  in  which  this 
treatment  was  used  led  to  the  following  conclusions  : 

In  one  sense  the  treatment  was  successful,  in  that  it  in  great 
degree  relieved  the  symptoms  throughout  the  course  of  the  dis- 
ease and  enabled  the  patients  to  go  about  in  the  open  air,  to 
attend  to  school,  and  even  to  join  in  the  games  of  their  fellows. 
It  was  evident,  however,  from  an  inspection  of  the  patients  as 

1  Ridlon.    Loc.  cit. 

-  Sasse.    Arbeit  aus  der  klin.  Chir.,  Berlin,  1896.    Bruns,  Archiv  f.  klin.  Chir.,  Bd.  xlviii. 
H.  1. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT.  357 

they  returned  for  treatment,  that  the  relief  of  symptoms  was  due 
to  the  protection  insured  by  the  stilting  or  crutch-like  action  of 
the  brace  and  not  by  traction,  which  was  usually  simply  traction 
in  name,  not  in  fact.  But  if  the  brace  relieved  the  symptoms,  it 
did  not,  in  many  instances,  prevent  deformity  ;  and  as  the  preven- 
tion of  deformity  is  an  object  only  secondary  in  importance  to  the 
relief  of  pain,  the  treatment  was  in  so  far  unsatisfactory.  This 
deformity  was  usually  flexion,  occasionally  combined  with  adduc- 
tion, a  deformity  often  increasing  slowly  without  pain,  or  other 
evidence  of  greater  activity  of  disease.  If  the  deformity  were 
reduced  by  traction  in  recumbency,  it  reappeared  when  ambu- 
latory treatment,  by  the  brace,  was  resumed.  This  flexion  seemed 
to  be  in  many  instances  simply  an  adaptation  to  the  prevailing 

Fig.  220. 


The  short  spica  bandage  reaching  to  the  knee  in  combination  with  the  brace.  One  perineal 
has  been  removed  in  order  to  show  how  the  joint  is  supported  by  the  bandage.  The  short 
spica  of  the  Lorenz  model  may  be  used  also  for  this  purpose. 

postures.  When,  for  example,  the  patient  assumed  the  sitting 
position,  the  limb  was  flexed  in  spite  of  the  brace,  and  as  much 
of  the  time  was  passed  in  this  attitude,  its  influence  on  the  pro- 
duction of  deformity  seemed  to  be  obvious. 

It  was  also  apparent  that  the  brace  was  not  effective  in  relieving 
pain  during  the  more  acute  exacerbations,  even  during  recum- 
bency with  such  traction  as  could  be  applied  by  the  parents ;  nor 
when  the  children  were  brought  in  arms  to  the  clinic. 

Under  these  conditions  it  was  found  that  acute  symptoms 
might  be  relieved,  or  greatly  modified,  almost  at  once,  by  the 
application  of  a  close-fitting  short  spica  bandage  extending  from 
the  middle  of  the  thorax  to  the  knee.  Over  this  the  brace  was 
applied  as  before,  making  an  apparatus  which  then  combined 
splinting,  traction,  and  stilting  (Fig.  220).     This  treatment  was 


358 


ORTHOPEDIC  SURGERY. 


repeated  in  many  instances,  always  with  the  same  result.  As 
the  application  of  the  plaster  bandage  was  a  somewhat  tedious 
proceeding,  it  was  often  exchanged  for  a  short  Thomas  splint 
worn  beneath  the  pelvic  band  of  the  traction  brace  in  the  same 
manner.  This  fixation  appliance  not  only  relieved  pain  in  the 
acute  cases,  but  it  also  prevented  the  deformity,  which  was  not 
checked  by  the  traction  brace  alone. 


Fig.  221. 


The  long,  inexpensive  brace,  with  solid  upright,  showing  the  perineal  bands  and  the 
adhesive  plaster,  as  used  in  hospital  practice. 

This  combination  of  the  short  Thomas  brace  and  the  traction 
hip  splint  is  effective  as  a  means  of  relieving  pain  and  preventing 
deformity.  It  has,  however,  the  disadvantage  of  requiring  careful 
adjustment,  and  it  obliges  the  patient  to  wear  shoulder  straps  ; 
in  other  words,  much  care  must  be  exercised  to  insure  the  com- 
fortable adjustment  of  both  appliances.  Thus  the  next  step  was 
the  combination  of  the  two,  even  though  the  action  was  somewhat 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


359 


less  effective.  To  the  pelvic  band  of  the  traction  brace  a  lateral 
thoracic  bar  was  attached,  reaching  upward  in  the  axillary  line  to  a 
point  opposite  the  middle  of  the  scapula,  where  it  was  joined  to  a 
metal  band  that  encircled  the  chest,  like  that  of  the  Phelps  brace. 
When  this  was  securely  fastened  about  the  chest,  the  body  and 
the  limb  were  held  in  line  by  a  long  lateral  brace ;  the  pelvis 
was  supported  by  the  pelvic  band  and  the  joint  received  the 
additional  protection  that  was  assured  by  traction  and  stilting 
(Figs.  221  and  222). 

This  brace  and  another  form  similar  in  principle,  in  which  the 
upright  of  the  thoracic  attachment  is  fixed  posteriorly  to  the 
pelvic  band,  are  now  in  general  use  at  the  Hospital  for  Ruptured 
and  Crippled.  The  efficiency  of  this  brace  may  be  still  further 
increased  by  replacing  the  perineal  bands  by  a  metallic  ring. 
This  ring,  which  fits  the  upper  extremity  of  the  thigh  closely,  is 


Fig.  222. 


The  long  hip  split  applied. 


attached  to  the  upright  at  an  inclination  corresponding  to  the 
line  of  the  groin  (Fig.  223).  (The  Thomas  ring  described  fully 
in  connection  with  his  knee  splint.)  It  is  a  better  support 
because  it  prevents  anteroposterior  motion  within  the  pelvic  band, 
which  the  perineal  straps  allow.  The  ring  may  be  used  as  the 
only  support  or  it  may  be  combined  with  a  perineal  band  on  the 
opposite  side.  This  is  of  advantage  if  there  is  a  tendency  toward 
adduction. 

The  apparatus  is  most  satisfactory  when  the  hollow  upright  of 
the  Taylor  brace  is  used.  This  is  light  and  strong,  and  is  pro- 
vided with  an  arrangement  for  effective  traction,  but  in  hospital 
practice  the  upright  is  made  of  solid  metal,  and  the  traction  is 
made  by  simple  straps.  The  metallic  ring,  besides  providing 
better  fixation,  is  a  firm  support  that  cannot  be  removed  by  the 


sed. 


ORTHOPEDIC  SURGERY. 


patient.  It  is,  of  course,  more  difficult  of  adjustment,  and  it  is 
not  suited  to  the  treatment  of  young  children  because  of  the 
difficulty  in  keeping  it  clean  and  dry. 

The  Thomas  ring  was  first  applied  to  a  hip  splint  by  Phelps 
(Fig.  225).     He  has  always  urged  the  advantages  of  fixation  and 


Fig.  223. 


Fig.  224. 


The  long  brace,  with  Thomas  ring  and  ex- 
tension upright,  similar  to  Phelps'  brace. 


Rear  view  of  brace. 


traction,  and  his  brace,  of  which  that  last  described  is  simply  a 
slight  modification,  is  provided  with  an  arrangement  for  lateral 
traction.      Practically  speaking,  this  is  a  tape  by  which  the  lower 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT. 


361 


third  of  the  thigh  is  held  in  apposition  to  the  upright.  It  hardly 
seems  possible  that  appreciable  lateral  traction  can  be  exerted  on 
the  joint  by  this  means  if  the  metallic  ring  is  properly  fitted  to 
the  thigh.  The  simple  straps  do  not  afford  as  effective  traction 
as  the  rack  and  pinion,  nor  is  the  brace,  as  usually  constructed, 
sufficiently  strong  to  bear  the  weight  of  the  body  without  bend- 


FlG.  225. 


The  Phelps  hip  splint. 


A  chair  to  be  used  with  the  long  hip  splint.  The 
patient  sits  upon  the  sound  side,  while  the  splinted 
half  of  the  body  remains  in  the  extended  position,  the 
brace  resting  on  the  floor. 


ing.  It  should  be  stated,  however,  that  this  form  of  brace  is 
intended  to  be  used  with  crutches  rather  than  as  a  walking  appli- 
ance. 

Many  objections  to  this  attempt  to  combine  effective  splinting 
without  traction  and  stilting  have  been  urged  by  those  who  believe 
in  tlie  efficiency  of  the  ordinary  traction  brace.  For  example,  it  is 
said  that  the  splinting  is  ineffective  because  the  movements  of  the 
tnuik  are  transmitted  to  the  joint,  while  this  is  not  true  of  braces 
that  do  not  extend  al)ove  the  pelvis.  In  reply  it  may  be  stated 
that  the  traction  part  of  the  coni})iiied  splint  remains  as  effective 


362  ORTHOPEDIC  SUBOEBY. 

as  before ;  thus  it  follows  that  this  suggestion  is  an  acknowledg- 
ment of  the  fact  that  the  theory  of  motion  without  friction  is  no 
longer  tenable.  As  a  matter  of  experience,  however,  it  will  be 
found  that  motion  of  the  upper  part  of  the  trunk  is  absorbed,  as 
it  were,  in  the  flexible  lumbar  region  of  the  spine  before  it  reaches 
the  joint.  If,  however,  such  motion  or  any  motion  causes  dis- 
comfort or  aggravates  the  symptoms,  the  patient  should  be  con- 
fined in  the  recumbent  posture  until  the  acute  phase  of  the  disease 
is  passed. 

It  is  said  that  the  brace  is  cumbersome,  that  the  patient  cannot 
sit  with  comfort,  and  that  it  prevents  normal  activity. 

A  long  brace  certainly  weighs  more  than  a  short  one,  and  if  a 
brace  prevents  flexion  of  the  hip  and  spine  it  is  evident  that  the 
patient  cannot  sit  with  comfort  in  an  ordinary  chair. 

As  a  matter  of  fact,  the  patients  themselves  make  little  com- 
plaint of  the  brace,  even  when  it  has  been  substituted  for  an 
ordinary  traction  splint;  while  the  greater  restraint  of  activity 
is  a  favorable  element  of  treatment,  since  children  who  do  not 
suffer  pain  are  much  more  likely  to  be  too  active  than  to  be  harm- 
fully restrained  by  any  form  of  appliance.  These  objections  are 
trivial,  if  one  is  convinced  that  the  dangerous  and  deforming  dis- 
ease that  is  under  treatment  may  be  more  easily  controlled  and 
that  the  final  result  is  likely  to  be  better  and  to  be  more  rapidly 
attained  by  this  means  than  by  another. 

It  would  be  of  advantage,  of  course,  if  a  brace  could  be  so 
adjusted  to  the  pelvis  and  to  the  femur  as  to  fix  the  joint  without 
interfering  with  the  motion  of  the  spine.  Satisfactory  fixation 
can  be  attained,  however,  only  by  a  close-fitting  plaster  bandage 
of  the  Lorenz  model  (Fig.  211).  This  should  be  applied  over 
the  traction  plasters,  and  the  traction  hip  brace  is  then  adjusted. 
This  method  of  treatment  is  the  most  effective  that  can  be  em- 
ployed, but  it  must  be  renewed  at  frequent  intervals  if  ''  ideal " 
fixation  is  desired. 

This  long  brace  is  used  exactly  as  is  the  ordinary  traction 
brace.  If  deformity  be  present  it  is  reduced  by  one  or  another 
of  the  methods  that  have  been  described.  If  the  disease  is 
acute,  recumbency  and  traction  are  employed  until  this  stage  is 
passed. 

When  ambulation  is  resumed  crutches  may  be  employed  for  a 
time,  but  during  the  greater  part  of  the  treatment  the  brace  is 
used  as  a  walkmg  appliance,  as  accurate  splinting  and  as  effective 
traction  being  employed  during  this  period  as  circumstances  will 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


563 


Fig.  227. 


permit.  If  the  joint  continues  to  be  sensitive  the  short  spica 
plaster  should  be  applied  in  the  manner  described,  to  be  worn 
beneath  the  brace.  If  one  desires  to  exert  lateral  traction  the 
upper  part  of  the  thigh  may  be  drawn  outward  by  means  of  a 
bandage  attached  to  the  junction  of  the 
pelvic  band  and  the  upright  of  the 
brace. 

During  the  entire  course  of  treat- 
ment supervision  of  the  patient,  with 
the  aim  of  adapting  activity  to  the  local 
weakness,  should  be  exercised,  even 
though  it  may  be  less  essential  than 
when  other  apparatus  is  employed. 

The  impression  that  one  might  re- 
ceive from  descriptions  of  the  treat- 
ment of  hip  disease  is  that  most  cases 
begin  acutely,  or  that  when  the  patients 
are  brought  for  treatment  the  disease 
is  in  an  acute  stage,  or  that  deformity 
is  present,  so  that  preliminary  recum- 
bency is  required.  But  each  year  the 
proportion  of  early  cases  is  greater, 
cases  in  which  there  is  no  deformity 
and  in  which  acute  symptoms  are  ab- 
sent. In  such  instances  the  hip  splint 
may  be  applied  without  preliminary 
recumbency,  and  if  the  joint  is  fixed 
in  the  normal  attitude  and  protected 
a  relatively  rapid  recovery  without  de 


'  ^  -  .  The  Taylor  hip  splint  as  used  by 

formity  and  with  a  fair  range  of  motion     Taylor  in  the  later  years  of  his 

practice    with   but   one    perineal 
band. 

The  cut  shows  also  an  appliance 
for  preventing  or  for  correcting 
slight  degrees  of  adduction,  while 
the  brace  is  in  use  as  a  walking  ap- 
pliance. The  abduction  bar  is 
disease    is    still    active    than    to    decide     bucWed  about  the  upper  extremity 

of  the  other  thigh.    (H.  L.  Taylor, 
Medical  News,  March  23, 1889.) 


may  be  hoped  for. 

The  Treatment  of  Hip  Disease  during 
the  Stage  of  Recovery.  It  is  much 
easier    to    assure    one's    self    that  the 


when  it  is  cured.     For  the  symptoms 

may  have  been  quiescent  for  months  or 

years  even,  under  the  protective  treatment,  and  yet  they  may 

recur  on  the  slightest  provocation  when  this  treatment  has  been 

discontinued. 

To  judge  of  the  probable  duration  of  the  disease  in  a  given 
case,  one  must  consider  its  area,  its  quality,  and  its  complica- 


364 


ORTHOPEDIC  SURGERY. 


tions.  If,  for  example,  the  primary  symptoms  indicate  that  the 
focus  of  infection  is  of  limited  area  and  is  contained  within  the 
bone,  rapid  recovery,  possibly  in  a  year,  may  be  expected ;  but 
in    the    ordinary  type  of   disease  in  which  the   joint  has  been 


Fig.  228. 


Taylor's  median  abduction  brace  used  as  a  bed  splint  to  overcome  adduction  by  counter- 
pressure  on  the  sound  side. 

invaded,  repair  can  hardly  be  anticipated  in  less  than  three  or 
four  years.  Supposing  that  sufficient  time  has  elapsed  to  permit 
of  natural  cure,  if  there  have  been  no  symptoms  of  active 
disease  for  a  year  or  more,  and  if  muscular  spasm  is  absent,  one 
may  test  the  joint  by  removing  the  brace  at  night  to  ascertain  the 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT. 


365 


effect  of  simple  motion  without  weight  bearing.  Such  freedom 
will  enable  the  patient  to  move  the  knee,  which  having  been  fixed 
in  the  extended  position  for  so  long  usually  remains  stiff  for  a 


Fig.  229. 


Fig.  230. 


Judson's  perineal  crutch.  This  support 
suspended  from  the  shoulders  may  be  em- 
ployed as  a  substitute  for  axillary  crutches. 
It  is  also  used  as  a  convalescent  splint  in  the 
treatment  of  hip  disease. 

time;  in  fact,  several  months 
may  elapse  before  the  full  range 
of  motion  is  regained. 

It  is  well,  also,  to  remove 
the  thoracic  part  of  the  brace  to 
allow  the  patient  more  mobility 
at  the  hip.  At  a  later  time  the 
traction  may  be  discontinued  and 
the  brace  may  be  suspended  from 
the  shoulders  to  serve  as  a  per- 
ineal crutch  (Fig.  230)  ;  or  it 
may  be  attached  to  the  shoe  and 
so  adjusted  as  to  be  slightly 
longer  than  the  limb,  in  order  that  direct  concussion  and  pressure 
may  be  lessened  (Fig.  229).  Or  a  brace  jointed  at  the  knee, 
after  the  Taylor  pattern,  may  be  employed. 


Modified  brace  to  be  worn  during  conva- 
lescence. Same  patient  as  in  Fig.  224.  The 
thoracic  part  has  been  removed  and  the 
lower  end  of  the  stem  has  been  made  into  a 
cahper,  passing  through  the  heel  of  the  shoe. 
The  stem  is  extended  by  means  of  the  key 
until  the  heel  is  lifted  slightly  from  the  shoe; 
thus  the  hip  is  relieved  from  shock. 


366 


OB  THOPEDIC  SUEGEB  Y. 


This  brace  is  so  adjusted  as  to  be  slightly  longer  than  the  limb, 
so  that  the  heel  does  not  touch  the  bottom  of  the  shoe  (Fig.  232). 
Thus  the  weight  is  in  great  part  supported  on  the  perineal  band. 
The  weight  of  the  brace  may  be  in  part  supported  and  incidentally 


Fig.  231. 


Fig.  232. 


Convalescent  hip  splint,  allowing  motion  at  the  knee.    (Taylor.) 


slight  traction  may  be  exerted  by  adhesive  plaster  applied  above 
the  knee  (Fig.  233).  The  foot  plate,  to  which  the  upright  is 
attached,  is  shown  in  Figs.  232  and  234. 

As  the  strain  upon  the  part  is  increased,  one  watches  carefully 
for  the  return  of  muscular  spasm  or  for  restriction  of  the  range 
of  motion.  If  the  range  of  motion  does  not  diminish,  and  if  the 
deformity  that    may  be  present  does  not  increase  or  does  not 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


367 


appear  if  it  were  absent,  the  brace  may  be  removed  at  intervals  and 
finally  discarded. 

As  has  been  stated,  the  short  spica  after  the  Lorenz  model  is 
an  admirable  support  during  the  period  of  recovery.  It  prevents 
motion  at  the  joint,  yet  it  permits  the  function  of  support,  and 
thus  a  gradual  rebuilding  of  the  bony  structure  which  has  become 
atrophied  during  the  course  of  the  disease.     By  means  of  this 


Fig.  233. 


Fig.  234. 


Fig.  235. 


0 


Details  of  the  Taylor  convalescent  hip  brace. 
Fig.  233,  the  adhesive  plaster.  Fig.  234,  the  foot 
plate  showing  the  method  of  attachment. 


The  action  of  the  Taylor  convalescent 
hip  brace  in  removing  direct  pressure 
illustrated  by  wooden  model. 


appliance  the  limb  may  be  held  in  the  desired  position  of  slight 
abduction,  and  it  is  particularly  effective  when  the  limb,  because 
of  destructive  changes  in  the  joint,  is  inclined  toward  adduction. 
It  should  be  stated  that  the  long-continued  fixation  of  the  limb 
combined  witli  traction   may  induce  laxity  of  the  ligaments  and 


368 


ORTHOPEDIC  SURGERY. 


hyperexteusion  at  the  knee,  unless  it  is  properly  supported  by 
the  posterior  thigh  band.  In  the  cases  in  which  the  atrophy  is 
extreme  and  in  which  this  laxity  is  present  the  splint  may 
be  discarded  in  favor  of  the  fixation  bandage  with  advantage 
(Fig.  231). 

This  period  of  supervision  even  in  favorable  cases  should  be 
protracted,  for  no  patient  can  be  considered  free  from  the  danger 
of  relapse  for  a  long  time  after  apparent  cure.  If  there  is  firm 
bony  anchylosis,  as  in  exceptional  cases,  cure  is  assured ;  but  if 
there  is  simple  fibrous  anchylosis,  and  particnlarly  if  there  is 
upward  displacement  of    the  trochanter,   there  is  a  strong  ten- 


Fli;.  236. 


Double  hip  disease,  terminating  iu  bony  anchylosis. 

dency  toward  flexion  and  adduction,  even  though  the  disease 
is  cured.  In  such  cases  it  is  often  necessary  to  employ  appar- 
atus at  intervals  to  reduce  the  deformity  or  to  hold  the  limb  in 
proper  position  until  stability  is  assured.  When  the  brace  has 
been  discarded,  the  patient  should  be  trained  to  walk  with  equal 
steps,  placing  the  limb,  as  far  as  possible,  on  an  equality  with  its 
fellow  and  adapting  in  like  manner  the  stronger  to  the  weaker 
member. 

This  has  an  important  influence  in   checking  the  tendency  to 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


369 


deformity  and  in  modifying,  or  even  concealing,  the  limp,  a  point 
to  which  Judson  has  repeatedly  called  attention. 

Bilateral  Hip  Disease. 

Ninety-five  cases  of  bilateral  hip  disease  were  treated  in  the 
Hospital  for  Ruptured  and  Crippled  during  a  period  of  ten  years 
ending  in  1899. 

As  a  rule,  the  second  hip  is  affected  some  time  after  the  symp- 
toms of  disease  of  the  first  have  been  apparent,  but  occasionally 
both  joints  are  involved  simultaneously.  In  most  instances  the 
symptoms  are  rather  subacute,  owing,  very  likely,  to  the  fact 
that  the  activity  of  the  patient  is  so  restricted. 

Fig.  237. 


Left  hip  disease,  showing  swelling  caused  by  abscess,  also  the  absence  of  flexion  deformity. 


Treatment.  The  treatment  is  similar  in  principle  to  that  of 
the  unilateral  form.  The  patient  during  the  greater  part  of  the 
course  of  the  disease  must  be  confined  in  the  recumbent  position, 
although  not  necessarily  in  bed.  The  double  Thomas  hip  splint 
is  a  convenient  means  of  fixation.  With  this  apparatus  extension 
by  means  of  the  weight  and  pulley  may  be  employed,  or  the 
brace  may  be  so  modified  as  to  provide  independent  traction.  If 
the  disease  of  one  hip  is  acute  and  is  attended  by  abscess  forma- 
tion, excision  for  the  purpose  of  lessening  the  strain  upon  the 
patient  may  be  advisable. 

If  motion  is  greatly  restricted  in  both  joints  locomotion  unless 
crutches  are  used  is  very  difficult,  as  motion  at  the  knees  can 
supply  only  in  small  part  the  function  of  the  hip-joints.  In  such 
instances  excision  of  one  hip  in  the  hope  of  obtaining  a  certain 
amount  of  motion  may  be  considered. 

24 


370 


OB  TH  OPE  Die  S  UB  QEB  Y. 


Hip  Disease  Combined  with  Disease  of  Other  Parts. 

The  most  common  combination  is  with  Pott's  disease.  The 
two  processes  may  be  primarily  distinct,  but  occasionally  it  would 
appear  that  the  disease  of  the  hip  is  caused  by  the  infection  of  an 

abscess,   which,  coming  from 
^^'     '  the  spine,  remains  for  a  long 

time  in  contact  with  the  cap- 
sule of  the  joint.  In  five  of 
one  hundred  and  fifty  cases  of 
disease  of  the  hip-joint  of 
which  the  final  results  were 
reported  by  Gibney,  AVater- 
man,  and  Reynolds  (page  387), 
Pott's  disease  was  a  complica- 
tion, in  two  instances  preced- 
ing and  in  three  following  the 
disease  at  the  hip.  The  com- 
bination of  the  two  diseases 
makes  the  mechanical  treat- 
ment difficult.  Recumbency 
offers  the  best  opportunity  for 
the  effective  adjustment  of 
apparatus  when  the  disease  of 
either  part  is  acute.  At  a 
later  period  crutches  may  be 
employed,  together  with  the 
necessary  braces. 

Hip  Disease  in  Infancy. 

Hip  disease  in  infancy  is 
far  less  common  than  in  early 
childhood.  It  presents  noth- 
ing of  special  interest  except 

Untreated    hip  diseflse.    Slight   flexion   and       ^  .  pp  xi.      j? 

adduction  (apparent  s-hortenlng).    The  scar  of     that    itS   eitect  Upon  trie  tunc- 

?he°thigh^^'''''  ''  '''°  °''  '^'  '''''''  ^''"''  ''^     ^^^^^  0^  ^^^  j^^°^  ^^^  "P^""  *^^ 

development  of  the  limb  is 
usually  more  marked  than  in  older  subjects.  Tuberculous  disease 
of  this  joint  must  be  differentiated  from  infectious  epiphysitis,  in 
which  prompt  operative  treatment  is  indicated.  A  modified 
Thomas  brace  is  most  efficient  in  treatment  (Fig.  208). 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.         371 

Hip   Disease   in  the  Adult. 

Hip  disease  in  the  adult  may  present  the  typical  symptoms  of 
the  ordinary  form,  but  it  is  usually  of  the  more  subacute  type. 
]S  ot  infrequently  it  is  a  complication  of  tuberculosis  of  the  lungs. 

The  subacute  form  of  tuberculous  disease  is  often  difficult  to 
distinguish  from  osteoarthritis,  if  this  is  confined  to  the  hip- 
joint.  Gonorrhoeal  arthritis  and  impacted  fracture  of  the  neck 
of  the  femur  may  be  mentioned  also  in  differential  diagnosis. 
The  mechanical  treatment  is  not  difficult,  but  in  many  instances 
early  excision  may  be  advisable  in  order  to  bring  about  a  rapid 
cure  of  the  disease.  This  is  far  more  important  than  in  child- 
hood, because  few  adults  can  afford  the  time  required  for  the 
natural  cure,  and  because  in  many  instances  the  general  con- 
dition of  the  patient  may  demand  relief  from  the  depressing 
effects  of  the  local  disease,  especially  if  it  be  complicated  by 
suppuration. 

Abscess  in  Hip  Disease. 

It  may  be  assumed  that  a  limited  collection  of  the  fluid  prod- 
ucts of  the  tuberculous  process  is  present  in  nearly  every  case  of 
hip  disease  in  which  the  joint  surfaces  are  actually  involved.  In 
many  instances  it  remains  within  the  joint.  In  a  larger  propor- 
tion of  the  cases  the  capsule  is  perforated,  the  fluid  escapes,  and, 
if  the  quantity  is  sufficient  to  form  an  appreciable  tumor,  it  is 
classed  as  an  abscess.  Such  abscesses  may  be  detected  in  about 
50  per  cent,  of  the  cases  that  are  treated  under  ordinary  con- 
ditions. 

In  1370  final  results  collected  from  various  sources  the  per- 
centage of  abscess  was  as  appears  in  the  following  table  : 

39  cases  reported  by  Shaffer  and  Lovetti 69  per  cent. 

82      ' Gibney2 60  " 

390      "  "         "  Bruns,3  Tubingen 58.3  " 

568      "  "         "   Koenig,*  Gottingen 56.5  " 

125      "  "         "   Sasse,!)  Berlin 50  " 

82  "           "         "  Prendlsburger,'^  Vienna    ....  51  " 

84  "     in  private  practice,  C.  F.  Taylor'         ....  25  " 

Most  often  the  abscess  first  appears  upon  the  anterior  and 
upper  part  of  the  thigh,  in  the  space  between  the  sartorius  and 

1  New  York  Medical  Journal,  May  21,  1887. 

2  New  York  Medical  Ilecord,  March  2,  1878. 
••'  Beit,  zur  kliii.  Chir.,  1895,  Bd.  xxx. 

■•  Die  Spec.  Tuberculose  der  Knoch  u  Gelenke,  Berlin,  1902. 

s  Arbeit  aus  der  Chir.  klinik  der  K.  Univ.  Berlin  (Bergmann's  clinic),  1896. 

"  Behand.  derGelenktubcrculose  und  ihre  Kndresultate  aus  der  klinik  Albert,  Wien,  1894. 

7  Boston  Medical  and  Surgical  .Journal,  March  6,  1879. 


372 


ORTHOPEDIC  SUBGEBY. 


tensor  vaginae  femoris  muscles.  In  other  instances  it  may  be 
detected  first  on  the  inner  side  of  the  thigh,  or  it  may  form  a 
tumor  beneath  the  gluteal  muscles,  its  situation  being  influenced 
by  the  point  at  which  the  capsule  is  ruptured. 

In  rare  instances  the  acetabulum  may  be  perforated  and  a 
pelvic  abscess  may  be  formed,  or  the  pus  may  find  its  way  into 
the  pelvis  along  the  iliopsoas  muscle ;  and  occasionally  a  pelvic 
abscess  may  exist  which  appears  to  have  no  direct  communica- 
tion with  the  joint. 

According  to  Koenig^  the  weakest  point  of  the  capsule  is  in 
the  anterior  wall,  where  it  is  covered  by  the  iliopsoas  muscle  and 
by  its  bursa,  which  often  communicate  with  the  joint.  A  second 
weak  place  is  iQ  the  posterior  wall. 

In  a  total  of  321  abscesses  in  hip  disease  recorded  by  Koenig 
the  situation  was  as  follows  : 

On  the  inner  side  (inside  the  femoral  artery) 26 

Front  of  the  joint  (between  artery  and  anterior  superior  spine)    .  126 

Region  of  the  trochanter 63 

Posterior  surlace 49 

In  the  pelvis 41 

In  other  situations 16 

The  tuberculous  abscess  is  a  symptom  and  common  accompani- 
ment of  hip  disease,  which,  in  cases  treated  under  proper  condi- 
tions, is  not  of  great  importance ;  and  yet,  on  the  other  hand,  it 

Fig.  239. 


Abscess  in  hip  disease.    The  brace  is  provided  with  the  Thomas  ring  and  with  the 
ratchet  extension. 


is  recognized  as  a  dangerous  complication.  It  is  dangerous  to 
life  because  of  the  profuse  suppuration  that  may  follow  infection, 
and  to  function  because  of  the  adhesions  and  contractions  that 


1  Loo.  cit. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  373 

may  result.  This  is  evident  in  all  statistics.  It  is  clearly  shown 
in  those  o£  Bruns.  In  this  list  the  mortality  in  the  non-sup- 
purative  cases  was  23  per  cent.,  and  of  the  suppurative  52  per 
cent. 

The  Significance  of  Abscess.  If  abscess  appears  early  in  the 
course  of  the  disease,  it  usually  indicates  that  it  is  of  a  destruc- 
tive character,  and  that  the  interior  of  the  joint  is  involved  ; 
therefore,  perfect  function  is  less  likely  to  be  preserved  than  in 
those  cases  in  which  the  disease  has  been  coniined  to  the  interior 
of  the  bone. 

Abscess  formation  is  often  preceded  by  an  acute  exacerbation 
of  symptoms,  by  pain,  by  an  increase  of  muscular  spasm  and 
consequent  distortion,  and  often  by  an  elevation  of  temperature. 
These  acute  symptoms  subside  and  a  fluctuating  swelling  appears. 
It  may  be  inferred  that  the  pain  in  such  a  case  was  due  to  the 
tension  of  the  abscess  within  the  capsule,  and  that  the  relief  of 
pain  followed  perforation  and  the  escape  of  the  fluid. 

In  perhaps  the  larger  proportion  of  cases,  more  especially 
those  in  which  the  joint  has  been  protected,  the  formation  of  the 
abscess  is  not  preceded  by  acute  symptoms,  such  as  have  been 
described.  Its  appearance  is  long  delayed,  and  but  for  the  swell- 
ing its  presence  would  not  be  suspected. 

As  the  progress  of  the  disease  is  influenced  by  the  strain  and 
injury  to  which  the  part  is  subjected,  so  abscess,  a  symptom  of 
disease,  is  more  common  in  those  cases  in  which  early  and 
efficient  treatment  has  been  neglected  ;  for  the  same  reason  its 
subsequent  course  is  directly  influenced  by  the  protection  that 
the  diseased  joint  receives. 

The  danger  from  abscess  is,  of  course,  infection.  Occasionally 
the  abscess  may  become  infected  before  an  opening  forms.  Such 
infection  may  be  inferred  when  the  tissues  about  the  abscess  are 
hot  and  sensitive,  and  when  fever  is  present ;  but,  as  a  rule,  the 
abscess  is  sterile  until  the  skin  is  perforated.  If  the  abscess  sac 
is  small  and  if  drainage  is  efficient,  and  especially  if  communica- 
tion with  the  joint  has  been  occluded,  infection  is  of  slight  con- 
sequence. But  if  before  the  opening  has  formed  the  abscess  has 
perforated  intermuscular  fasciae  and  has  extended  between  the 
layers  of  muscles  in  various  directions,  infection  is  likely  to  cause 
severe  local  and  constitutional  symptoms.  The  thigh  becomes 
the  seat  of  an  infectious  cellulitis,  pockets  of  pus  form,  which 
cannot  be  properly  drained ;  hectic,  emaciation,  and  loss  of  appe- 
tite follow,  and  if  the  profuse  discharge  of  pus  persists  amyloid 


374  OB THOPEDIC  S UB GEB  Y. 

degeneration  of  the  internal  organs  may  result.  Such  patients 
are  said  to  die  of  exhaustion  but  the  cause  of  exhaustion  is  an 
infected  abscess. 

Treatment.  Admitting  that  abscess  is  a  symptom  whose 
importance  stands  in  direct  relation  to  the  care  that  has  been 
exercised  in  the  treatment  of  the  disease,  and  that  in  the  better 
class  of  cases  the  danger  from  this  source  is  slight,  still  it  is  also 
true  that  abscess  is  the  chief  cause  of  danger,  and  almost  the 
only  cause  of  death,  in  hip  disease  per  se.  One's  views  as  to  the 
treatment  are  likely  to  be  influenced  by  the  class  of  cases  with 
which  he  is  most  familiar.  Some  surgeons  have  advocated  abso- 
lute non-interference  with  the  symptomatic  abscess  on  the  ground 
that  in  many  instances  it  finally  disappears  by  spontaneous 
absorption,  while  in  other  cases  the  long  delay  allows  the  com- 
munication with  the  joint  to  close,  so  that  the  danger  of  infection 
after  an  opening  has  formed  is  slight.  Finally,  that  the  results 
after  non-interference  are  better  than  those  reported  after  opera- 
tive treatment.  Others  insist  that  all  collections  of  fluid  of  this 
character  should  be  evacuated  as  soon  as  they  are  discovered, 
because  of  the  danger  of  infection  before  an  opening  forms  and 
because  of  the  advantage  gained  by  preventing  burrowing  of 
pus.  Little  could  be  said  against  this  latter  course  were  it  not 
that  infection  is  as  common  after  operative  treatment  as  when  a 
spontaneous  opening  forms;  the  only  advantage  in  favor  of  the 
artificial  opening  being  that  the  cavity  with  which  it  communi- 
cates should  be  smaller  and  more  direct  than  when  the  fluid 
has  undermined  the  tissues  in  various  directions,  but  this  is  offset 
by  the  fact  that  at  least  20  per  cent,  of  abscesses  disappear  with- 
out treatment.  In  fact,  as  compared  with  indiscriminate  incisions, 
the  let-alone  treatment  should  be  preferred  when  proper  after- 
treatment  cannot  be  assured. 

It  would  appear,  however,  that  the  middle  course,  between  the 
extremes,  is  the  safest,  and  especially  so,  as  by  far  the  larger 
number  of  patients  must  be  treated  under  conditions  that  do  not 
permit  of  proper  care.  In  the  outdoor  department  of  the  Hos- 
pital for  Ruptured  and  Crippled  abscesses  are  treated  symptomat- 
ically.  If  a  swelling  appears  but  remains  quiescent  and  causes 
no  symptoms,  it  is  not  disturbed.  If  it  enlarges,  the  tension  of 
the  fluid  is  relieved  by  aspiration,  which  may  be  repeated  as 
required,  compression,  after  the  evacuation  of  the  fluid,  being 
applied  by  means  of  a  pad  and  bandage.  If  the  abscess  is  on 
the  point  of  opening  spontaneously,  or  if  its  contents  are  of  such 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.         375 

a  nature  that  aspiration  is  impossible,  an  incision  is  made  and 
the  proper  dressings  are  applied ;  or,  if  the  child  lives  at  a  dis- 
tance from  the  hospital,  the  mother  is  instructed  in  the  manner 
of  dressing  and  as  to  the  importance  of  cleanliness. 

If  the  abscess  is  of  large  size,  or  if  acute  symptoms  are  present, 
the  child  is  admitted  to  the  hospital.  Here  the  same  general 
principle  is  followed,  but  at  the  present  time  the  routine  of  treat- 
ment of  non-infected  abscess  is  free  incision  that  will  allow  com- 
plete evacuation  of  its  contents.  The  abscess  membrane  is 
removed  by  gently  rubbing  with  iodoformized  gauze.  If  the 
opening  in  the  capsule  of  the  joint  is  exposed,  this  may  be  en- 
larged to  permit  the  evacuation  of  the  products  of  disease  within 
the  joint ;  at  the  same  time  the  character  and  extent  of  the  dis- 
ease may  be  ascertained,  and  foci  may  be  removed  if  practicable ; 
the  wound  is  then  closed  with  superficial  and  deep  sutures,  and  a 
firm  dressing  is  applied.  This  operation,  if  performed  under 
aseptic  precautions,  causes  no  disturbance,  and  it  relieves  nature 
from  the  burden  of  necrotic  material  which  must  be  an  obstacle 
to  spontaneous  absorption.  In  many  instances  the  abscess  is 
permanently  cured,  although  if  the  condition  that  induced  it  re- 
mains unchanged  fluid  will  again  accumulate,  and  if  so  a  spon- 
taneous opening  will  form  in  the  line  of  the  incision.  This  oper- 
ation is  not  a  radical  cure  of  the  abscess  or  of  the  disease ;  it 
is  simply  a  means  of  thorough  evacuation  for  the  purpose  prima- 
rily of  accomplishing  what  the  aspirator  does  only  in  part.  If 
the  abscess  has  become  infected  its  contents  are  completely 
removed,  the  wound  is  then  packed  with  gauze,  and  provision 
is  made  for  efficient  drainage. 

In  the  treatment  of  abscesses  the  injection  of  iodoform  emulsion, 
in  connection  with  the  aspiration  or  incision  has  been  thoroughly 
tested.  The  results,  as  far  as  the  disappearance  of  the  abscess 
was  concerned,  were  not  as  good  as  from  simple  aspiration  ;  and 
as  the  procedure,  being  somewhat  of  the  nature  of  an  operation, 
caused  the  patients  some  discomfort  and  anxiety,  it  was  discon- 
tinued. From  the  clinical  standpoint  there  is  little  evidence 
that  these  injections  exercise  any  particular  influence  upon  the 
disease,  but,  theoretically,  iodoform  should  lessen  the  infectious- 
ness of  the  tuberculous  fluid,  and  by  local  irritation  stimulate  the 
growth  of  granulation  tissue.  There  appears  to  be  no  serious 
objection  to  its  use. 

The  Treatment  of  Sinuses.  When  the  disease  is  active  the 
sinuses  that  serve  as  drains  should  not  be  interfered  with.     And 


376  ORTHOPEDIC  SURGERY. 

in  the  advanced  cases  when  the  disease  is  quiescent  and  when 
the  tissues  about  the  joint  are  of  the  peculiar,  resistant,  "  porky  " 
consistency,  active  measures,  either  for  the  purpose  of  closing 
sinuses  or  for  the  correction  of  deformity,  should  be  de- 
ferred. In  many  instances,  however,  sinuses  persist  as  tuber- 
culous fistulse,  serving  no  useful  purpose.  In  this  class  the  com- 
plete removal  of  the  infected  tissue  by  excision  or  by  thorough 
curetting  is  the  most  effective  remedy.  The  various  applications 
of  pure  carbolic  acid,  solution  of  salicylic  acid,  iodoform  emul- 
sion, balsam  of  Peru,  and  the  like  are  of  some  service,  but 
thorough  removal  of  the  disease  is  the  only  radical  treatment. 

Exploratory  Operations.  In  certain  instances  exploratory  opera- 
tions may  be  indicated.  If,  for  example,  pain  and  swelling  indi- 
cate tension  within  the  capsule  it  may  be  relieved  by  an  incision 
and  the  joint  may  be  explored  with  the  possibility  of  finding  a 
localized  focus  of  disease  that  may  be  removed. 

The  joint  may  be  opened  by  an  anterolateral  incision,  begin- 
ning one  inch  to  the  outer  side  of  the  anterior  superior  spine  and 
extending  downward  about  three  inches.  This  exposes  the  line 
of  junction  between  the  tensor  vaginte  femoris  and  the  gluteus 
medius  muscles.  When  these  are  separated  from  one  another  the 
anterior  surface  of  the  capsule  of  the  joint  is  laid  bare.  If  more 
room  is  required  the  tensor  vaginae  femoris  muscle  may  be 
divided.  The  capsule  is  then  incised  in  the  line  of  the  neck  and 
through  the  incision  the  head  of  the  bone  may  be  extruded  by 
rotating  the  limb  outward  and  extending  it.  By  this  means  the 
character  of  the  disease  may  be  ascertained  and  in  certain  in- 
stances localized  foci  in  the  neck  or  in  the  head  of  the  bone  may 
be  removed.  The  wound  is  then  closed  or  drained  as  may  seem 
advisable.  By  such  intervention  the  course  of  the  disease  may 
be  shortened,  although  cure  by  this  means  is  unusual. 

Temporary  anterior  dislocation  of  the  head  of  the  femur  by 
means  of  the  anterolateral  incision  may  be  of  value  in  acute  and 
painful  disease.  Posterior  dislocation  for  this  purpose  has  been 
performed  by  Bradford  in  several  cases  with  satisfactory  results, 
the  bone  being  again  replaced  when  the  disease  had  become  qui- 
escent.^ The  object  of  this  operation  is  to  remove  the  opposing 
bones  from  direct  contact,  and  to  relieve  the  muscular  spasm  that 
accompanies  acute  disease. 

Exploratory  operations  also  may  be  of  special  value  in  the 

>  Transactions  of  the  American  Orthopedic  Association,  vol.  xiii. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  2,11 

later  stages  of  the  disease,  to  ascertain  the  cause  of  loug-con- 
tinued  suppuration,  or  of  abnormal  delay  in  repair,  which  may  be 
due  to  detached  or  adherent  fragments  of  necrosed  bone  within 
the  joint.  This  point  is  illustrated  by  the  statistics  of  61  cases 
of  hip  disease  treated  by  excision  by  Poor.^  In  15  of  these  loose 
bone  was  found  in  the  joint,  and  in  7  the  head  of  the  bone  was 
detached. 

In  98  cases  investigated  by  Lehman^  at  the  Wiirzburg  Clinic 
sequestra  were  present  in  20.4  per  cent.,  and  in  70  per  cent,  of 
88  cases  treated  by  Riedel.^ 

An  exploration  of  the  joint  by  one  familiar  with  surgical 
technique  should  be  free  from  danger,  and  it  may  be  of  much 
value. 

Excision  of  the  Hip.  The  operation  of  excision  is  now  classed 
as  a  treatment  of  necessity  in  certain  cases,  usually  those  in 
which  recovery  under  conservative  treatment  is  considered  very 
doubtful.  For  example,  when  there  is  progressive  failure  in 
health  ;  when  it  is  impossible  to  drain  the  joint  effectively  after 
infection  ;  when  there  is  evidence  of  extension  of  the  disease  to 
the  shaft  of  the  femur  or  to  the  pelvic  cavity,  or  when  other 
serious  complications  exist. 

In  certain  instances  the  excision  may  follow  an  exploratory 
operation  ;  in  such  cases  the  anterolateral  incision  may  be  em- 
ployed and  the  neck  and  head  of  the  bone  only  may  be  removed. 
In  this  operation  the  diseased  tissue  is  removed  as  thoroughly  as 
possible  with  the  sharp  spoon,  by  scrubbing  with  iodoformized 
gauze,  and  by  flushing  with  hot  water.  If  the  joint  is  not 
infected  it  is  dried  ;  iodoform  emulsion  may  be  injected  or  the 
pure  carbolic  acid  may  be  applied,  and  the  various  tissues  are 
then  sewed  in  layers  ;  pressure  is  applied,  the  aim  being  to  secure 
immediate  union.  If  this  does  not  take  place  drainage  is 
employed  in  the  usual  manner. 

In  typical  cases  the  operation  is  performed  because  of  exten- 
sive disease  and  infected  abscess,  and  in  such  instances  the  entire 
upper  extremity  of  the  bone  to  the  trochanter  minor  is  removed. 

A  satisfactory  method  is  that  of  Koenig. 

An  incision  about  five  inches  in  length  is  made  in  a  line  join- 
ing the  trochanter  and  the  posterior  inferior  spine  of  the  ilium. 
About  two-thirds  of  the  length  is  above  and  one-third  over  the  tro- 
chanter.    The  incision  is  deepened  to  expose  the  capsule  and  the 

'  New  York  Medical  Journal,  April  23,  1892.  2  inaug.  Diss.,  Wiirzburg,  1896. 

2  Centralbl.  f.  Chir.,  1893,  Bd.  xx.,  Nos.  7  and  8. 


378  ORTHOPEDIC  SURGERY. 

surface  of  the  trochanter,  from  which  one  removes  the  insertion 
of  the  gluteus  maximus  and  the  tendons  of  the  medius  and 
minimus.  The  muscles  are  separated  in  the  line  of  the  incision 
and  the  capsule  is  widely  opened.  With  a  thick,  strong  knife 
one  separates  all  the  muscular  attachments  to  the  anterior  margin 
of  the  trochanter,  while  the  limb  is  rotated  outward,  removing, 
if  possible,  a  thin  section  of  periosteum  and  bone.  The  same 
process  is  then  repeated  on  the  posterior  surface,  the  limb  being 
rotated  inward.     The  trochanter  is  then  removed. 

The  acetabular  insertion  of  the  capsule,  together  with  the 
adjoining  upper  border  of  the  acetabulum,  is  then  cut  away  and 
the  neck  of  the  femur  is  separated  from  the  shaft  with  a  saw 
or  chisel.  All  the  diseased  parts  are  then  removed,  including 
the  acetabular  wall  and  adjoining  bone,  if  necessary.  The  wound 
is  partly  closed  with  drainage,  and  the  extremity  of  the  femur  is 
placed  within  the  acetabulum,  where  it  should  be  retained  for  a 
time  by  a  plaster  bandage  or  Thomas  brace  provided  with  trac- 
tion straps.  When  the  patient  begins  to  walk  a  hip  splint  or 
other  support  is  used  for  a  time  to  prevent  deformity.  One  of 
the  most  efficient  supports  of  this  class  is  the  short  or  Lorenz 
spica,  the  limb  being  fixed  in  an  attitude  of  overextension  and 
moderate  abduction  for  many  months. 

The  success  or  failure  of  excision  of  the  hip  as  a  life-saving 
operation,  provided  the  diseased  bone  has  been  removed,  is  de- 
cided by  the  after-treatment,  and  in  this,  drainage  is  the  great 
essential.  The  opening  must  be  large  and  the  shaft  of  the  bone 
must  be  drawn  down  by  efficient  traction,  so  that  it  may  not  ob- 
struct the  opening,  and  the  exuberant  granulation  must  be 
removed  from  time  to  time.  Phelps  has  introduced  a  valuable 
adjunct  in  the  use  of  short,  glass  drainage  tubes  of  large  diameter, 
even  up  to  one  and  one-half  inches.  Through  such  a  tube  or 
speculum  the  gauze  is  inserted,  the  opening  permitting  thorough 
inspection. 

The  importance  of  an  open-air  life  after  these  operations  can 
hardly  be  exaggerated.  The  lack  of  this,  the  inefficiency  of  the 
after-treatment  in  securing  proper  drainage,  and  the  postponement 
of  the  operation  until  amyloid  changes  are  advanced  explain  the 
unsatisfactory  character  of  the  results. 

The  functional  results  after  excision  in  this  class  of  cases  are 
not  as  good  as  those  that  may  be  obtained  when  the  operation  has 
been  performed  at  an  earlier  period.  If  motion  continues  free  the 
joint  is  usually   insecure.     In  many  instances  there  is  upward 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT.         379 

displacement  of  the  shaft  of  the  femur  upon  the  ilium  with  con- 
sequent flexion  and  adduction  deformity,  while  in  a  third  class  of 
cases  a  movable  joint  of  sufficient  strength  may  be  preserved. 
The  ultimate  shortening  is  considerably  greater  than  after  con- 
servative treatment.  This  is  accounted  for  by  the  upward  dis- 
placement of  the  femur  and  by  the  removal  of  the  two  epiphyses 
of  its  upper  extremity. 

In  a  period  of  twelve  years,  1888  to  1899,  inclusive,  149  opera- 
tions of  excision  were  performed  at  the  Hospital  for  Ruptured  and 
Crippled.  During  this  time  1283  cases  of  hip  disease  were  treated 
in  the  wards  and  1870  new  cases  were  recorded  in  the  out-patient 
department.  Thus  the  operation  was  performed  in  11.6  per  cent, 
of  those  in  the  hospital,  but  the  relative  frequency  of  the  opera- 
tion in  the  entire  number  of  patients  under  treatment  was  con- 
siderably less  than  this. 

One  hundred  and  twenty-one  of  these  operations  of  excision, 
or  those  performed  prior  to  1897,  have  been  carefully  analyzed 
by  Townsend.i  The  121  operations  were  performed  on  119 
patients,  in  two  instances  both  hips  having  been  operated  upon. 
In  113  abscesses  or  sinuses  were  present,  in  most  instances 
infected.  In  5  cases  the  spine  was  involved  as  well  as  the  hip  ; 
in  2  instances  the  knee  ;  in  2  the  tarsus  ;  in  3  the  ilium.  In  24 
cases  the  anterior  incision  was  employed,  in  97  the  posterior. 
In  18  instances  the  acetabulum  was  seriously  diseased,  and  in 
10  osteomyelitis  of  the  shaft  of  the  femur  was  present.  This 
indicates  the  character  of  the  disease  in  the  cases  operated 
upon. 

In  99  of  the  119  cases  the  later  results  of  the  operation  were 
ascertained.  Of  these  52  were  dead  and  47  were  living.  Of  the 
52  deaths  9  were  due  directly  to  the  operation,  shock  ;  28  were 
caused  by  exhaustion  (persistent  suppuration) ;  9  by  tuberculous 
meningitis;  7  by  other  causes.  Thirty-seven  deaths  occurred 
within  six  months  and  10  others  within  one  year  of  the  operation. 
Of  the  47  patients  living  at  the  time  of  the  investigation,  26 
were  cured.  Of  the  remaining  number  about  one-half  were  in 
poor  condition,  so  that  recovery  could  not  be  expected.  It  is 
evident  that  in  a  large  proportion  of  the  cases  the  operation  was 
unsuccessful  as  a  life-saving  measure,  since  suppuration  per- 
sisted. 

The  functional  results  in  these  cases  are  shown  in  the  follow- 
ing table  : 

1  Medical  News,  June  26,  1897. 


380 


ORTHOPEDIC  SURGERY. 


Table  Showing  Shortening,  Motion,  Number  of  Sinuses  Present, 
AND  Angle  of  Greatest  Extension  in  Forty-seven  Cases  of 
Excision,     (Townsend.) 


No. 

Time  since 

General  con- 

Sinuses 

Angle  of 

greatest 

extension. 

Motion  in 

Shortening 

operation. 

dition. 

present. 

degrees. 

in  inches. 

1 

6^  years 

Good 

3 

150 

0 

2>^ 

2 

6^    " 

Fair 

1 

135 

0 

4 

3 

6       " 

Good 

0 

180 

100 

3 

4 

53^      " 

" 

0 

180 

35 

3 

5 

5»4    " 

Fair 

0 

145 

10 

4 

6 

5>^    " 

Good 

1 

165 

0 

2>l 

7 

5 

" 

0 

155 

5 

8 

4K     " 

" 

3 

160 

0 

2H 

9 

4>^     " 

" 

0 

160 

0 

'm 

10 

4K     " 

" 

0 

165 

0 

1'/ 

11 

4 

" 

0 

150 

0 

1% 

12 

4 

Poor 

4 

0 

13 

3}^    " 

Good 

0 

155 

0 

14 

3>^     " 

" 

0 

160 

30 

1 

15 

3 

Poor 

1 

165 

0 

H 

16 

2        " 

Fair 

2 

145 

30 

% 

17 

2        " 

Good 

18 

2 

Fair 

1 

170 

0 

X 

19 

2 

Good 

0 

150 

0 

K 

20 

Wx     " 

" 

0 

175 

y2 

21 

Wa     " 

" 

0 

165 

30 

22 

^%     " 

" 

0 

150 

0 

1 

23 

iy2  " 

" 

0 

150 

0 

VA 

24 

IK    " 

" 

1 

180 

0 

% 

25 

11/    " 

Fair 

6 

175 

15 

1 

26 

1 

Poor 

2 

165 

0 

2M 

27 

1 

Good 

0 

170 

0 

28 

1 

" 

0 

155 

0 

1 

29 

1 

" 

0 

175 

0 

Yi 

30 

1 

Poor 

0 

180 

10 

1^ 

31 

11  months 

" 

3 

170 

0 

Vx 

32 

10 

" 

0 

180 

40 

ly* 

33 

10       " 

Good 

3 

165 

0 

% 

34 

10 

" 

0 

160 

0 

X 

35 

10 

" 

1 

165 

0 

1 

36 

10        " 

Poor 

1 

160 

0 

% 

37 

10 

Good 

3 

155 

10 

IM 

38 

9 

" 

1 

0 

P 

39 

9 

" 

0 

40 

9 

Poor 

1 

170 

'o 

/2 

41 

9 

Fair 

3 

1 

42 

8 

Good 

0 

180 

130 

'4 

43 

8 

" 

0 

180 

44 

8 

Poor 

1 

165 

10 

H 

45 

7 

" 

46 

7 

Good 

0 

180 

10 

^Vx 

47 

7 

0 

160 

70 

V. 

Lovett^  has  reported  the  results  of  50  excisions  in  a  similar 
class  of  cases  at  the  Boston  Children's  Hospital,  1877  to  1895. 
The  number  of  patients  actually  treated  in  the  wards  of  the  hos- 
pital is  not  stated,  but  1100  cases  were  recorded  as  having  been 
under  treatment  during  this  time,  a  percentage  of  excisions  of 
4.5  of  the  total  number.  In  8  of  the  cases  osteomyelitis  of  the 
femur  was  present,  and  in  15  the  acetabulum  was  perforated. 
The  ultimate  mortality  was  about  50  per  cent. 

Poor^  has  reported  the  results  in  65  cases  operated  upon  at  St. 


1  Transactions  American  Orthopedic  Association,  vol.  x. 

2  New  York  Medical  Journal,  April  23,  1892. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.  381 

Mary's  Hospital,  New  York,  with  a  final  mortality  of  about  43 
per  cent.  In  21  cases  osteomyelitis  of  the  shaft  of  the  femur 
was  present.  In  11  cases  there  was  perforation  of  the  acetabulum, 
and  in  9  of  these  the  opening  communicated  with  an  intrapelvic 
abscess. 

These  statistics  are  quoted  to  illustrate  the  relative  efficiency 
of  late  excision.  The  extent  of  the  lesions  in  some  of  the  cases 
shows  that  recovery  would  have  been  impossible  without  opera- 
tion, and  its  failure  to  relieve  the  symptoms  in  so  many  instances 
is  sufficient  evidence  that  it  was  postponed  too  long.  Under 
proper  conditions  for  treatment  excision  of  the  hip  is  almost 
never  required,  but  in  hospital  practice  it  should  be  performed 
oftener  and  earlier  in  the  course  of  the  disease. 

Amputation.  Amputation  at  the  hip  should  follow  excision 
when  suppuration  persists  and  when  the  condition  of  the  patient 
does  not  improve,  provided  the  internal  organs  are  not  hopelessly 
diseased.  The  operation  of  amputation  after  complete  excision  is 
a  simple  procedure  and  it  should  not  be  attended  with  great  danger. 

Reduction  of  Deformity  in  Resistant  Cases.  The  various  methods 
of  reducing  deformity  during  the  active  stages  of  the  disease  have 
been  described,  and  the  importance  of  preventing  deformity 
throughout  the  entire  course  of  treatment  has  been  insisted  on. 
At  the  present  time,  for  one  reason  or  another,  deformity  from 
this  cause  is  very  common,  either  because  its  importance  is  not 
appreciated  or  because  it  is  considered  as  a  necessary  concomitant 
of  the  disease,  treated  by  apparatus,  as  it  is  in  the  natural  cure. 
At  all  events,  in  many  instances  it  is  allowed  to  persist  until  the 
accommodative  changes  about  the  diseased  joint  have  so  fixed  the 
limb  in  the  deformed  position  that  greater  correcting  force  is 
required  than  can  be  applied  by  the  weight  and  pulley  or  by 
other  method  of  traction. 

In  this  class  of  cases,  in  which  the  muscles  are  structurally 
shortened  and  in  part  transformed  to  fibrous  tissue,  and  in  which 
the  anterior  wall  of  the  capsule  has  become  retracted  and  it  may 
be  adherent  to  the  surrounding  parts,  forcible  reduction  under 
anaesthesia,  or  osteotomy,  may  be  required.  If  the  disease  is 
quiescent  or  cured,  if  the  head  of  the  femur  or  what  remains  of 
it  is  in  the  normal  position,  and  if  a  fair  range  of  motion  re- 
mains, gradual  forcible  reduction,  after  division  of  the  bands  of 
fascia  or  the  muscles  that  hold  the  limb  in  the  deformed  position, 
is  advisable. 

In  all  cases  in  which  the  head  of  the  articulation  is  destroyed 


382 


ORTHOPEDIC  SURGERY. 


the  aim  should  be  to  secure  an  anterior  transposition  of  the  upper 
extremity  of  the  femur,  and  to  secure  this  result  one  proceeds 
as  in  reducing  or  transposing  the  congenitally  displaced  hip — 
by  longitudinal  traction,  by  forcible  abduction,  combined  with 
massage  of  the  adductors,  and,  finally,  by  gradual  extension — 
preceded  usually  by  division  of   the    resistant  parts  about  the 


Fig.  240. 


Extreme  deformity  after  hip  disease,  showing  the  attitude  before  operation. 
(See  Figs.  241  and  242.) 

anterior  superior  spine.  The  limb  is  then  fixed  by  a  Lorenz 
spica  in  an  attitude  of  moderate  abduction  and  overextension. 
Later  the  abduction  is  lessened  by  the  overextended  position  ;  this 
is  maintained  for  many  months,  and  is  assured  by  passive  move- 
ments after  the  support  is  removed.  Forcible  reduction  in  cured 
or  quiescent  cases  is  practically  free  from  danger. 

The  Correction  of  Deformity  by  Femoral  Osteotomy.  If  the 
deformity  is  fixed  by  bony  anchylosis  or  by  firm,  fibrous  adhesions 
within  the  joint ;  or  if  it  is  feared  that  violence  may  stimulate 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT. 


383 


dormant  disease ;  or  if  there  is  such  a  degree  of  upward  displace- 
ment of  the  femur  upon  the  pelvis  that  the  deformity  is  likely  to 
recur  after  replacement,  it  is  better  to  correct  the  deformity  by  an 
osteotomy  of  the  femur. 

The  patient  having  been  prepared  for  operation,  is  turned  upon 
the  side  and  a  sand-bag  is  placed  between  the  thighs.  A  small 
osteotome,  about  the  shape  of  a  lead-pencil,  of  which  one  extremity 
is  flattened  to  a  cutting  edge  (Vance's  instrument),  is  pushed 
directly  through  the  soft  parts  to  the  femur  at  a  point  about  two 
inches  below  the  apex  of  the  trochanter.  It  is  turned  until  its 
cutting  edge  is  at  the  right  angle  to  the  shaft  and  it  is  then 
driven  through  the  cortical  substance  of  the  bone.  When  it  has 
penetrated  at  one  point  it  is  withdrawn,  and  adjoining  portions 
are  cut  until  about  half  the  circumference  is  divided,  when  with 


Fig.  241. 


The  favorite  attitude  in  recumbency.    (See  Fig.  240.) 

slight  force  the  bone  may  be  fractured.  If  the  deformity  is  of 
long  standing,  division  of  the  contracted  tissues  in  the  adductor 
region  and  below  the  anterior  superior  spine  may  be  required. 

The  limb  is  then  drawn  down  to  complete  extension  and 
moderate  abduction,  and  the  body  and  limb  are  encased  in  a 
plaster-of- Paris  spica  bandage,  which  should  remain  in  position 
for  several  months,  although  the  patient  may  be  allowed  to  bear 
weight  on  the  limb  in  a  few  weeks  after  the  operation.  The  long 
may  be  replaced  by  the  short  spica  at  the  end  of  two  months. 
This  latter  or  some  similar  appliance  should  be  used  until  tests 
show  that  there  is  no  longer  danger  of  recurrence  of  the  deformity. 

The  advantages  of  the  subcutaneous  method  are  simplicity  and 
freedom  from  danger.  No  dressings  are  required,  except  a  pad 
of  gauze  over  the  minute  opening,  thus  the  limb  may  be  firmly 
held  by  the  plaster  bandage.  If  there  is  anchylosis  between  the 
femur  and  the  pelvis  no  snpj)ort  will   be  required  after  the  bone 


384 


ORTHOPEDIC  SURGERY. 


Fig.  242. 


has  united,  but  if  there  is  motion  in  the  joint  some  fixative  appli- 
ance should  be  employed  for  a  time  to  prevent  recurrence  of  a 
part  of  the  deformity. 

Prognosis.     Mortality.     The  direct  mortality  of  hip  disease  is 
due  almost  entirely  to  the  immediate  or  remote  effects  of  abscess. 

This  is  illustrated  by  the  statistics  of 
Bruns,  in  which  the  mortality  from  all 
causes  of  the  non-suppurative  cases  was 
23  per  cent,  as  compared  with  52  per 
cent,  in  those  in  which  suppuration  was 
present. 

The  mortality  among  the  patients 
treated  at  many  of  the  German  clinics 
is  much  higher  than  in  the  corresponding 
class  in  this  country. 

At  Tubingen,  according  to  AYagner,^ 
it  was  40  per  cent. 

At  Kiel,  according  to  Mummelthy,  it 
was  48.59  per  cent,  in  non-operative 
cases  and  53.96  per  cent,  in  -operative 
cases. 

At  Marburg,  according  to  Marsch,  it 
was  35  per  cent,  in  non-operative  cases 
and  40.4  per  cent,  in  operative  cases. 

At  Heidelberg,  according  to  Huis- 
mans,Mt  was  46.6  per  cent,  in  non-oper- 
ative cases  and  58  per  cent,  in  operative 
cases. 

At  Zurich,  according  to  Pedolin,^  it 
was  37.7  per  cent,  in  non-operative  cases 
and  54  per  cent,  in  operative  cases. 

At    A^ienna,    according    to    Prendls- 
burger,*  it  was  17  per  cent,  in  all  classes. 
At  Gottingen,  according  to  Koenig,^ 
40.3  per  cent. 

In  a  total  of  636   cases  treated   by  conservative  methods  by 
Rabl,  1859  to  1894,  definite  results  were  ascertained  in  519  f 


After  correction  by  osteotomy 
and  division  of  the  contracted 
tissues.  (Gibney.)  (See  Figs.  240 
and  241.) 


1  Beit.  z.  klin.  Chir.,  1895,  Bd.  xiii. 

2  Quoted  by  Binder,  Zeits.  f.  Orthop.  Chir.,  1889,  Bd.  vii.  H.  2  and  3. 

3  Centralbl   f.  Chir.,  July  25,  1896,  No.  30.  *  Loc.  cit. 

5  Koenis.    Das  Hoeftgeleuk,  Berlin,  1902. 

6  Zur  Conserv.  Behand.  der  tuberculosen  Knochen  und  Gclenksleiden,  J.  Rabl,  Leipzig 
und  Wien,  1895. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.         385 

335  were  hospital  cases.  Of  these  216  were  cured,  64.4  per 
cent. ;  70  died,  20.8  per  cent.,  and  49,  14.4  per  cent,  were  still 
under  treatment ;  184  were  treated  as  out-patients.  Of  these, 
132  were  cured,  71.5  per  cent.  ;  35  died,  19.2  per  cent.,  and  17, 
92  per  cent.,  remained  under  treatment. 

In  288  cases  treated  at  the  Hospital  for  Ruptured  and  Crippled, 
New  York,  reported  by  Gibney,^  the  death-rate  was  12.5  per 
cent. 

In  private  practice  the  statistical  reports  of  final  results  show 
the  death-rate  to  be  extremely  small.  C.  F.  Taylor,^  94  cases, 
including  24  in  which  suppuration  was  presented,  3  deaths. 
L.  A.  Sayre,^  212  cases,  5  deaths.  Lorenz,''  60  cases,  with  3 
deaths. 

In  the  clinics  of  this  country  the  death-rate  has  been  estimated 
to  be  from  10  to  15  per  cent.,  a  rate  of  mortality  much  lower 
than  that  reported  from  those  abroad.  This  is  accounted  for  in 
part  by  the  fact  that  patients  are  of  a  better  class  and  in  part 
because  they  receive  earlier  and  more  efficient  mechanical  pro- 
tection. 

The  causes  of  death,  according  to  Wagner's  statistics  of  124 
cases,  were  as  follows  : 

Hip  disease 35 

General  tuberculosis 37 

Tuberculous  meningitis 13 

Tuberculosis  of  the  lungs      .       .       .       .  ' 11 

Acute  miliary  tuberculosis 5 

Amyloid  degeneration 8 

Septic  infection 12 

Intercurrent  disease 3 

124 

Thirty  per  cent,  of  the  deaths  occurred  in  the  first  year  of  the 
disease,  26  per  cent,  in  the  second  year,  and  20.4  per  cent,  in  the 
third  year. 

The  percentage  of  recovery  was  65  per  cent,  of  those  in  the 
first  decade  of  life,  56  per  cent,  of  those  in  the  second,  and  but 
28  per  cent,  of  those  in  the  third  decade. 

The  causes  of  death  in  50  cases  among  778  patients  treated  at 
the  New  York  Orthopedic  Dispensary  and  Hospital  during  the 
years  1877  to  1882  were  :^ 

1  New  York  Medical  Journal,  July  and  August,  1877, 

2  Boston  Medical  and  Surgical  Journal,  March  6, 1879. 

3  New  York  Medical  Journal,  April  30,  1892. 
<  Wiener  Klinik,  1892.  10  and  11. 

'"  Shaffer  and  Lovett.    New  York  Medical  Journal,  May  21,  1887. 

25 


386  ORTHOPEDIC  SURGERY. 

Tuberculous  meningitis 20 

Amyloid  degeneration 5 

Exhaustion 3 

Tuberculosis  of  the  lungs 3 

Tuberculous  peritonit's 1 

Septicemia 1 

Convulsions 1 

Unknown 16 

50 

Of  96  deaths  recorded  at  the  Alexandra  Hospital,  London  (a 
mortality  of  about  26  per  cent,  of  the  cases  treated),  the  causes 
were 

Tuberculous  meningitis .       .  16.1  per  ct. 

Albuminuria  and  dropsy 20.8  " 

Tuberculosis  of  the  lungs 8.3  " 

Exhaustion 9.4  " 

Erysipelas  and  pysemia 3.1  " 

After  operation 9.4  " 

Intercurrent  diseases 7.3  "' 

Unknown 25.0  " 

100.0 

The  direct  mortality  of  hip  disease  should  include  all  deaths 
due  to  operation,  those  caused  by  exhaustion  and  amyloid  degen- 
eration, which  is  almost  always  the  result  of  profuse  suppuration 
secondary  to  pyogenic  infection.  Tuberculous  meningitis,  a  com- 
mon and  apparently  an  unavoidable  cause  of  death,  is  not  neces- 
sarily a  complication  of  the  local  disease,  except  in  so  far  as  a 
lowered  vitality  may  predispose  the  patient  to  it,  since  it  may 
have  been  due  to  new  infection  or  induced  by  the  primary  focus 
which  preceded  the  tuberculosis  of  the  hip. 

It  is  believed  that  operative  interference  is  sometimes  the  direct 
cause  of  tuberculous  meningitis,  and  it  is  of  interest  in  this  con- 
nection to  note  that  20  of  50  deaths,  or,  rather  of  34,  in  which 
the  cause  of  death  was  known,  58  per  cent,  were  due  to  this 
complication  among  the  cases  treated  at  the  New  York  Ortho- 
pedic Dispensary  and  Hospital,  where  no  operations  were  per- 
formed.^ While  of  52  deaths  in  a  total  of  99  cases  treated  at 
the  Hospital  for  Ruptured  and  Crippled,  in  which  excision  was 
performed,  but  9  were  caused  by  tuberculous  meningitis.^ 

The  normal  death-rate  among  cases  under  fair  hygienic  condi- 
tions is  illustrated  by  statistics  from  the  Hospital  for  Ruptured 
and  Crippled  at  a  time  when  no  operative  or  mechanical  treat- 
ment was  employed.^  This  was  12.5  per  cent.  ;  4.5  per  cent, 
from  exhaustion,  4.5  per  cent,  from  amyloid  degeneration,  1.75 

1  Shaft'er  and  Lovett.    New  York  Medical  Journal,  May  21,  1887. 

-  TowDsend.    Medical  News,  June  26,  1896. 

3  Gibney.    New  York  Medical  ilecord,  March  2, 1878. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT.         387 

per  cent,  from  tuberculous  meningitis,  1.75  per  cent,  from  inter- 
current diseases. 

Thus  nearly  75  per  cent,  of  the  deaths  were  due  more  or  less 
directly  to  suppuration. 

Functional  Results.  In  a  certain  proportion  of  cases  perfect 
function  may  be  retained,  the  proportion  depending  upon  the 
extent  of  the  disease,  and  upon  the  timeliness  and  efficiency  of 
the  treatment. 

In  a  total  of  280  cases  from  the  private  practice  of  Dr.  L.  A. 
Sayre,^  in  which  the  final  results  were  known,  73,  or  26  per 
cent.,  recovered  with  perfect  motion,  and  120,  or  42  per  cent., 
retained  good  motion.  These  results  are  extraordinarily  good, 
very  much  better  than  any  others  that  have  been  reported,  and, 
of  course,  far  better  than  may  be  expected  in  the  ordinary  class 
of  cases. 

The  effect  of  mechanical  treatment  and  of  the  various  measures 
employed  for  the  correction  of  deformity  is  well  illustrated  in 
two  series  of  ultimate  results  in  cases  treated  at  the  Hospital  for 
Ruptured  and  Crippled,  reported  by  Gibney.^  In  the  first  series 
of  80  cases  no  mechanical  or  operative  measures  were  employed, 
the  treatment  being  simply  hygienic  and  symptomatic ;  the 
results,  therefore,  represent  natural  cure  under  proper  super- 
vision. The  duration  of  the  disease  was  three  years  in  23  ;  three 
to  six  years  in  28  ;  six  to  ten  years  in  16,  and  fifteen  years  in 
one  case. 

In  35  cases  the  shortening  was  two  inches  or  more,  and  in 
nearly  every  case  there  was  more  or  less  deformity,  viz.  : 

In   2  there  was  flexion  to 90° 


"  3 
"  3 
"  19 
"  19 
"  18 
"  11 


.  110 
.  120 
.  135 
.  145 
.  150 
160-170 


In  4  no  estimate  was  made.  Distortions  other  than  flexion 
are  not  specified. 

In  12  instances  motion  was  retained  of  from  15  to  90  degrees. 

In  the  second  series^  of  107  cured  cases  mechanical  and  opera- 
tive treatment  was  employed,  although  the  protection  assured 
was  in  many  instances  far  from  efficient.  In  many  of  these  cases 
the  disease  was  in  an  advanced  stage,  and  deformity  was  present 

'  New  York  Medical  Journal,  April  30, 1892.  2  Loc.  cit. 

*  Gibney,  Waterman,  and  Reynolds.    Trans.  Amer.  Orth.  Assoc,  1898,  vol.  xi. 


388  OB THOPEDIC  S  UB GEB  Y. 

in  more  than  half  of  the  number  when  treatment  was  begun,  and 
yet  all  of  them  recovered  without  marked  flexion  and  presumably 
without  adduction,  as  this  deformity  is  not  mentioned. 

No  flexion .       ,        .47 

Flexion  of  10° 30 

of  10-20° 20 

"       of  20-30° 10 

Perfect  motion  was  retained  in 13 

Good          "         "          "        •• 22 

Limited     "          "           <i        ■< 4j 

There  was  anchylosis  in         ....•..,.  31 

In  69  cases  the  shortening  was  one  inch  or  less,  35  having  no 
shortening.     In  f38  it  was  more  than  one  inch. 

As  has  been  stated,  the  mechanical  treatment  in  these  cases 
was  not  sufficiently  effective  to  prevent  deformity,  and  to  attain 
these  results  osteotomy  with  or  without  division  of  contracted  tis- 
sues was  performed  in  19  cases,  forcible  correction  with  or  with- 
out tenotomy  in  30  cases,  and  in  4  cases  the  joint  was  excised. 

If  the  joint  has  been  actually  invaded  by  disease  so  that  a  part 
of  its  articulating  surface  has  been  destroyed,  motion  must  be 
impeded  both  in  area  and  quality.  In  such  cases  the  joint  is 
somewhat  weakened,  and  it  is  often  sensitive,  although  in  many 
instances  not  to  the  extent  of  interfering  seriously  with  the  ability 
of  the  patient.  In  this  class  discomfort  in  damp  weather  or  pain 
on  overexertion  is  experienced,  symptoms  similar  to  those  com- 
plained of  by  rheumatic  subjects. 

Simple  shortening,  due  to  retardation  of  growth,  unaccom- 
panied by  deformity,  is  of  comparatively  little  importance. 
Firm  anchylosis  in  a  symmetrical  position  insures  a  strong  and 
useful  limb,  the  flexibility  of  the  lumbar  region  compensating  for 
the  loss  of  motion  at  the  joint.  In  such  cases  the  disability  may 
be  very  slight,  and  the  effect  of  the  loss  of  motion  may  be  more 
apparent  in  the  sitting  than  in  the  erect  posture,  for  the  patient 
must,  as  it  were,  sit  upon  his  back,  an  attitude  which  perceptibly 
reduces  the  sitting  height. 

Flexion,  if  it  be  slight,  does  not  cause  disability,  but  flexion 
of  more  than  30  degrees  increases  the  lumbar  lordosis  and  makes 
the  buttock  prominent,  the  deformity  so  characteristic  of  the 
natural  cure  (Fig.  190).  Great  flexion,  for  example,  of  60  or  90 
degrees,  causes  an  exaggerated  lordosis  which  is  almost  always 
a  source  of  pain  or  discomfort  to  a  patient  who  is  obliged  to  stand 
much  of  the  time. 

Abduction  is  of  no  importance  unless  it  be  considerable.     It 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT.         389 

serves  in  most  instances  as  a  compensation  for  actual  shortening 
of  the  limb. 

Adduction,  on  the  other  hand,  which  necessitates  an  upward 
tilting  of  the  pelvis  in  order  to  restore  the  parallelism  of  the 
limbs,  is  the  most  disastrous  of  all  the  distortions  since  it  causes 
a  practical  shortening  often  greater  than  that  due  to  the  destruc- 
tive effects  of  the  disease. 

The  motion  that  is  retained  after  recovery  from  hip  disease  is 
usually  considered  as  the  test  of  successful  treatment.  This  is 
by  no  means  the  fact,  for  in  many  instances  motion  is  preserved 
because  the  joint  is  destroyed  and  because  what  remains  of  the 
upper  extremity  of  the  femur  is  supported  by  the  tissues  on  the 
dorsum  of  the  ilium — a  form  of  pathological  dislocation. 

In  such  cases  deformity  is  almost  always  present,  and  the  sup- 
port is  insecure. 

Deformity  is  far  more  disabling  than  loss  of  motion,  and  the 
best  safeguard  against  final  deformity  is  to  prevent  it  during 
treatment,  and  to  retain  as  far  as  may  be  the  joint  surfaces  in 
proper  relation  to  one  another.  Whatever  motion  is  preserved 
will  then  be  of  service  to  the  patient,  and  if  anchylosis  follows 
the  result  may  still  be  classed  as  good. 

Deformities  of  Other  Parts  Caused  by  Hip  Disease.  Deformities 
of  other  parts  are  sometimes  observed  as  secondary  results  of  hip 
disease,  most  often  in  cases  that  have  not  received  proper  treat- 
ment. In  the  spine  an  exaggerated  lordosis  as  a  compensation 
for  flexion  is  not  uncommon,  and  lateral  curvature  may  follow 
distortion  of  the  pelvis  caused  by  adduction.  In  the  limb  knock- 
knee  may  follow  persistent  adduction  of  the  thigh,  or  it  may  be 
an  effect  of  laxity  of  the  ligaments  without  such  distortion. 
Another  deformity  is  genu  recurvatum.  This  is  apparently  caused 
by  long-continued  disuse  of  the  limb,  and  by  the  use  of  apparatus 
in  which  the  knee  has  not  been  properly  supported.  It  is  sup- 
posed to  be  one  of  the  effects  of  traction,  but  it  is  also  observed 
in  cases  in  which  traction  has  never  been  employed.  In  cases  in 
which  the  muscular  atrophy  that  follows  limited  motion  and  long- 
continued  disuse  is  great,  laxity  of  the  ligaments  of  the  knee-joint 
is  common,  and  not  infrequently  subluxation  of  the  tibia  also. 
A  slight  degree  of  equinus  with  accompanying  exaggeration  of  the 
arch  is  not  uncommon  among  patients  who  have  been  treated  by 
the  traction  apparatus,  in  which  the  foot  is  pendent  and  in  which 
the  toes  are  often  inclined  downward  to  guide  the  brace  in  walk- 
ing.    Practically  speaking,  all  these  secondary  deformities  may 


390  ORTHOPEDIC  SURGERY. 

be  avoided  by  proper  supervision  of  the  patient  during  the  period 
of  treatment. 

As  a  rule,  patients  who  have  recovered  from  hip  disease  finally 
discard  all  apparatus,  or  at  most  use  only  a  cane  as  a  support, 
and  many  prefer  to  walk  habitually  on  the  toe  rather  than  to 
equalize  the  length  of  the  limbs  by  a  high  shoe. 

By  far  the  larger  number  of  this  class,  having  accommodated 
themselves  to  whatever  weakness  and  distortion  may  be  pres- 
ent, are  able  to  undertake  the  ordinary  occupations  of  life.  Of 
the  patients  cured  at  the  New  York  Orthopedic  Dispensary  and 
Hospital  in  the  report  already  referred  to,  in  whom  the  final 
results  as  regards  motion  and  symmetry  were  certainly  not  above 
the  average,  it  is  stated  that  there  was  not  a  single  individual 
who  was  incapacitated  from  doing  a  full  day's  work  at  his  or  her 
trade  or  occupation.  ISTone  used  crutches  and  but  one  used  a 
cane. 


+  25  per  ct. 


CHAPTER  VIII. 

NON-1  UBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT. 

The  relative  frequency  and  importance  of  the  various  affec- 
tions of  the  hip-joint  that  cause  disability  are  indicated  by  the 
following  statistics  of  Koenig's^  clinic  at  Gottingen  : 

Tuberculous  disease 568      =      75  per  ct. 

Infectious  diseases  after  typhoid  fever : 

Scarlatina  and  the  like 110 

Gonorrhoeal  arthritis 30 

Arthritis  deformans 22 

Injuries 11 

Contractions,  cause  unknown       ....  6 

Coxa  vara 5 

Tumors 2 

Pysemic  suppuration 3  j 

757 

Several  of  the  affections  enumerated  are  very  uncommon  in 
childhood,  while  injury  and  coxa  vara  are  relatively  more  im- 
portant. Coxa  vara  and  fracture  of  the  neck  of  the  femur  in 
early  life  are  considered  in  Chapter  XV. 

Traumatisms  at  the  Hip-joint. 

It  is  probable  that  injury  at  the  hip-joint,  caused  by  falls  or 
strains,  may  induce  congestion  about  the  epiphyseal  cartilage  of 
the  head  of  the  femur.  In  this  class  of  cases  there  is  usually 
discomfort  at  night  after  overexertion,  "  growing  pain,"  and 
there  may  be  a  limp  and  restriction  of  motion.  These  symp- 
toms may  disappear  in  a  few  days  or  they  may  recur  from  time 
to  time.  If  the  injury  is  more  severe  there  may  be  local  sen- 
sitiveness and  even  swelling — synovitis.  This  congestion,  with 
the  lessened  local  resistance  induced  by  it,  may  be  a  predisposing 
cause  of  tuberculous  disease.  It  is  probable,  also,  that  cases  of 
this  type  are  sometimes  mistaken  for  hip  disease  and  go  to  swell 
the  number  of  perfect  functional  results  that  are  attained  by  one 
or  another  system  of  treatment. 

Treatment.  All  cases  of  this  class  require  careful  treatment 
and  supervision.     Strains  or  other  injuries  in  young  children  are 

1  Das  Hoeftgelenk,  Berlin,  1002. 


392  OB  THOPEDIC  S  UB OEB  Y. 

best  treated  by  a  supporting  bandage  and  by  rest  in  bed  until 
the  symptoms  disappear.  If  the  sensitive  condition  persists, 
protective  treatment  by  a  brace,  preferably  the  ordinary  traction 
hip  splint,  or  by  a  short  plaster  bandage,  should  be  employed, 
the  diagnosis  being  reserved  until  it  is  made  clear  by  the  progress 
of  the  case.  Chronic  synovitis  of  the  hip-joint,  especially  in 
the  adolescent  or  adult,  unless  it  be  a  result  of  severe  injury,  is 
usually  tuberculous  in  character. 

Fracture  of  the  neck  of  the  femur,  epiphyseal  separation,  and 
coxa  vara  are  considered  in  another  section. 

Acute  Infectious  Arthritis— Acute  Epiphysitis  at  the  Hip-joint. 

Acute  epiphysitis,  caused  by  infection  with  pyogenic  germs,  is 
not  uncommon  in  infancy  and  early  childhood,  and  it  often 
passes  as  a  form  of  acute  tuberculous  disease.  Of  fifty-two  cases 
in  which  but  a  single  joint  was  involved  the  hip  was  affected  in 
twenty-six.^  In  some  instances  it  is  induced  or  favored  by 
injury,  in  others  it  is  secondary  to  an  infected  wound,  and  it  may 
follow  pneumonia  or  one  of  the  exanthemata.     (See  page  270.) 

Symptoms.  The  symptoms  are  of  sudden  onset,  accompanied 
usually  by  high  fever  and  prostration.  The  hip  becomes  swollen, 
hot,  and  sensitive  both  to  motion  and  pressure. 

Treatment.  The  treatment  is  early  and  free  incision  and 
efficient  drainage,  the  limb  being  afterward  supported  by  some 
form  of  splint.  The  suppuration  ordinarily  persists  for  several 
months  ;  the  epiphysis  is  usually  destroyed  in  whole  or  in  part, 
and  in  consequence  the  joint  becomes  somewhat  loose  and  flail-like 
(Fig.  243).  Many  of  these  cases  seen  in  later  years,  but  for 
the  history  and  the  scars  about  the  joint,  might  be  mistaken  for 
congenital  dislocation.  In  certain  instances  the  symptoms  are 
less  acute  and  the  diagnosis  from  tuberculous  disease  can  be 
made  positively  only  after  a  bacteriological  examination  of  the 
fluid  that  may  be  removed  from  the  joint  by  aspiration. 

In  the  class  of  cases  in  which  the  disease  is  confined  to  one 
joint  and  in  which  the  shaft  of  the  bone  is  not  involved,  the 
prognosis  is  good  if  the  pus  is  thoroughly  evacuated.  In  twelve 
cases  treated  at  the  Hospital  for  Ruptured  and  Crippled  there 
were  three  deaths.^  The  prognosis  as  to  function  under  these 
conditions  is  much  better  than  in  tuberculous  disease. 


1  Townsend.    American  Journal  of  the  Medical  Sciences,  January,  1890. 

2  Townsend.    Loc.  cit. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOlIsT.    393 

After  recovery  the  joint  should  be  supported  for  a  time  to 
prevent  upward  displacement.  If  the  head  of  the  femur  has 
been  destroyed  there  is  usually  upward  and  backward  displace- 
ment. This  induces  flexion  and  adduction  of  the  limb  and  great 
disability.  In  such  cases  one  should,  under  ansesthesia,  force  the 
femur  forward  to  the  neighborhood  of  the  anterior  superior  spine 
and  to  fix  it  there  for  a  long  period  by  the  application  of  a 
Lorenz  spica  bandage  applied  with  the  limb  in  an  attitude  of 
abduction  and  hyperextension.  The  operation  is  in  detail  similar 
to  the  Lorenz  method  for  replacing  the  congenital  dislocation. 
(See  Congenital  Dislocation  of  the  Hip.) 

Subacute  Arthritis. 

In  the  forms  of  arthritis  that  may  complicate  infectious  dis- 
eases several  joints  are  usually  involved,  and  the  affection  is 
often  subacute  in  character. 

Undoubtedly  there  are  mild  cases  of  infection  at  the  hip-joint 
terminating  in  partial  or  complete  recovery  without  operation. 
In  such  cases,  which  are  usually  classed  as  rheumatism,  there  is 
usually  some  infiltration  about  the  hip,  flexion  deformity,  limita- 
tion of  motion,  and  pain  or  discomfort  referred  to  the  affected  joint. 
A  satisfactory  treatment  is  the  application  of  ichthyol  ointment 
in  a  strength  of  about  25  per  cent.,  the  joint  being  fixed  by  a 
posterior  wire  splint  or  light  Thomas  hip  brace. 

Spontaneous  Dislocation  of  the  Hip-joint. 

If  the  hip-joint  becomes  distended  with  fluid  the  capsule  may 
be  ruptured  and  sudden  displacement  may  occur. 

Degez^  has  collected  from  literature  seventy-nine  cases  of  this 
character.  The  displacement  occurred  in  the  course  of  the  fol- 
lowing diseases  : 

Typhoid  fever 32 

Kheumatism 24 

Scarlatina 13 

Variola 3 

Gonorrhoeal  arthritis 3 

Grippe 2 

Erysipelas 1 

Eruptive  fever 1 

Such  accidents^  may  be  guarded  against  by  preventing  flexion 
and  adduction   of  the  limb  and  by  evacuation  of  the  fluid  that 

'  Revue  d'Orthopiiflie,  January  1,  1899. 

■^  Graflf.    Deutsche  Zeits.  f.  Chir.,  February,  1902. 


394 


ORTHOPEDIC  SUBGEBY. 


Fig.  243. 


distends  the  joint.  The  femur  should  be  replaced  as  soon  as 
possible  before  it  has  become  fixed  by  adhesions  and  contrac- 
tions. Even  in  this  class  of  cases,  in  which  treatment  has  been 
delayed  for  months,  by  means  of  preliminary  traction  and  by 
the  use  of  manual  force,  as  in  the  reduction  of  congenital  disloca- 
tion, one  may  succeed  in  replacing  the  femur.  In  cases  of  long 
standing  the  acetabulum  is  filled  with  new  material,  which  must 

be  removed  by  the  open  method  be- 
fore replacement  is  possible.  As  an 
alternative  operation  one  may  force 
the  head  of  the  femur  into  the  an- 
terior position  and  fix  the  limb,  for 
several  months,  in  the  attitude  of 
extension  and  abduction.  If  the 
outward  rotation  of  the  foot  is  exces- 
sive, or  if  a  tendency  toward  adduc- 
tion persists,  a  secondary  osteotomy 
of  the  shaft  below  the  trochanter 
minor  may  be  performed.  How- 
ever early,  reduction  is  accomplished, 
limitation  of  motion  is  to  be  expected, 
and  in  many  instances  absolute  an- 
chylosis. On  this  account  the  limb 
should  be  supported  for  a  time  in 
proper  position  in  order  to  prevent 
deformity. 

Gonorrhoeal  Arthritis. 

Gonorrhoeal  arthritis  of  this  joint 
is  an  affection  not  uncommon  in  adult 
life,  and  in  its  symptoms  and  effects 
it  may  resemble  tuberculous  disease 
or  perhaps  more  closely  osteo-ar- 
thritis.  The  treatment  of  infectious 
arthritis  in  general  is  discussed  else- 
where. Deformity  should  be  cor- 
rected by  rest  in  bed  with  traction,  and  protective  treatment 
should  be  employed  while  the  sensitiveness  persists.  The  short 
spica  plaster  bandage,  if  properly  applied,  is  a  satisfactory  sup- 
port. 


The  later  effect  of  acute  epiphysitis 
of  the  right  hip  at  three  months  of  age. 
The  scar  is  shown. 


NON-TUBEBGULOUS  AFFECTIONS  OF  THE  HIP-JOINT.     395 

Extra-articular  Disease. 

Occasionally  tuberculous  disease,  or  other  form  of  destructive 
ostitis,  may  begin  in  the  neighborhood  of  the  trochanter  major. 
The  symptoms  are  local  pain,  sensitiveness,  and  swelling  of  the 
soft  parts.  Later  thickening  and  irregularity  of  the  underlying 
bone  become  evident. 

The  symptoms  are  limp  and  discomfort.  If  the  disease  in- 
volves the  capsule  or  is  sufficiently  acute  to  cause  sympathetic 
congestion  of  the  joint,  there  may  be  limitation  of  motion  ;  but, 
as  a  rule,  this  is  slight  or  absent.  In  many  instances  the  focus 
in  the  bone  may  be  shown  by  an  X-ray  negative.  When  the 
disease  is  tuberculous  or  of  the  subacute  type,  abscess  in  the 
trochanteric  or  gluteal  region  may  be  the  first  indication  of 
disease. 

The  treatment  is  prompt  removal  of  the  focus  of  disease  before 
the  joint  or  the  shaft  of  the  femur  has  become  involved. 

Disease  of  the  pelvic  bones  in  the  neighborhood  of  the  joint 
may  simulate  hip  disease.  The  diagnosis  is  made  by  the  local 
swelling  and  sensitiveness,  and  by  the  freedom  of  motion  in  the 
directions  not  restrained  by  sensitive  tissues  that  are  involved 
in  the  disease. 

Gluteal  Bursitis.  An  enlargement  of  one  of  the  bursas  lying 
beneath  the  gluteal  muscles  may  cause  a  rounded,  fluctuating 
swelling  in  the  buttock.  It  may  be  painful  to  pressure  and  it 
usually  causes  a  limp  and  some  discomfort  on  motion,  dependent 
upon  the  degree  of  inflammation  that  may  be  present.  Occasion- 
ally the  bursitis  may  be  caused  by  injury,  but  in  most  instances 
it  is  the  result  of  tuberculous  infection.  The  bursa  may  com- 
municate with  a  diseased  hip-joint,  but  usually  it  is  a  distinct 
and  primary  affection. 

Iliopsoas  Bursitis.  The  iliopsoas  bursa  lies  in  front  of  the 
capsule  of  the  hip-joint,  extending  from  the  trochanter  minor  to 
and  sometimes  over  the  brim  of  the  pelvis.  Not  infrequently 
it  communicates  with  the  joint.  If  the  bursa  is  enlarged  it 
forms  a  swelling  in  Scarpa's  space  of  a  somewhat  quadrilateral 
form.  Sometimes  a  central  indentation  indicates  the  position  of 
the  iliopsoas  tendon. 

This  causes  a  distinct  enlargement  of  the  upper  and  inner  aspect 
of  the  thigh.  It  is  usually  accompanied  by  slight  flexion,  abduction, 
and  outward  rotation  of  the  limb,  an  attitude  that  relieves  the 
tension  on  the  sensitive  part.     Zuelzer  has  collected  from  litera- 


396  ORTHOPEDIC  SURGERY. 

ture  forty-five  cases  of  gluteal  and  fifteen  of  iliopsoas  bursitis. 
This  illustrates  the  relative  frequency  of  the  two  affections.^ 

Simple  bursitis  may  be  distinguished  from  disease  of  the  joint 
by  the  absence  of  characteristic  muscular  spasm  and  general  limita- 
tion of  motion.     Acute  inflammation  may  simulate  local  abscess. 

Treatment.  Chronic  disease  of  bursse  is  usually  tuberculous 
in  character.  Aspiration  and  injection  of  carbolic  acid  or  iodo- 
form emulsion  may  be  employed  as  primary  measures.  As  a 
rule,  however,  incision,  drainage,  or,  if  possible,  removal  of  the 
sac  is  indicated.  According  to  Lund,^  iliopsoas  bursa  may  be 
reached  easily  by  a  vertical  incision  between  the  femoral  artery 
and  the  crural  nerve. 

Malignant  Disease  about  the  Hip-joint. 

Carcinoma  of  the  upper  extremity  of  the  femur  is  almost 
always  secondary  to  a  primary  tumor  of  another  part  of  the 
body.  Sarcoma  is  far  less  frequent  in  this  situation  than  at  the 
knee.  The  character  of  the  disease  soon  becomes  evident  in  the 
general  enlargement  of  the  upper  extremity  of  the  thigh,  but  in 
the  early  stage  diagnosis  can  be  made  only  by  means  of  the 
X-ray  or  by  exploratory  incision. 

Cysts  of  the  Femur. 

In  extremely  rare  instances  cysts,  caused  apparently  by  inclu- 
sion of  a  displaced  portion  of  epiphyseal  cartilage,  may  cause 
enlargement,  weakening,  and  deformity  of  the  upper  extremity 
of  the  femur.  One  case,  in  a  boy  thirteen  years  of  age,  was 
treated  at  the  Hospital  for  Ruptured  and  Crippled.  The  symp- 
toms were  discomfort,  limp,  and  outward  bowing  of  the  upper 
third  of  the  femur.  Cure  followed  its  removal.  Cysts  may  be 
caused  also  by  localized  osteomyelitis  of  a  mild  character. 

Arthritis  Deformans. 

Osteoarthritis  of  the  Hip-joint.  Osteoarthritis  is  not  infre- 
quently confined  to  the  hip-joint.  In  this  form  it  is  an  affection 
of  adult  life  or  old  age  (malum  coxse  senile).  It  is  characterized 
in  its  later  stages  by  disappearance  of  the  cartilage  covering  the 
head  of  the  femur  and  by  an  eburnation  and  progressive  destruc- 
tion, or  wearing  away,  of  the  underlying  bone.    At  the  same  time 

1  Deutsche  Zeits.  f.  Chir.,  Bd.  1.  H.  1  and  2. 

2  Boston  Medical  and  Surgical  Journal,  September  25, 1902. 


NON-TUBEBCULOUS  AFFECTIONS  OF  THE  HIP-JOINT.     397 

there  is  formation  of  ecchondroses  about  the  junction  of  the  femur 
with  the  acetabukim,  which  become  ossified  into  irregular  masses 
of  bone.  In  the  early  stage  of  the  affection  the  fluid  within 
the  joint  may  be  increased  in  amount,  but  later  it  is  diminished 
in  quantity  and  changed  in  quality  as  the  synovial  membrane 
becomes  transformed  in  part  to  fibrous  tissue.  The  etiology  of 
the  affection  is  discussed  elsewhere.     (See  page  274.) 

Symptoms.  The  early  symptoms  are  usually  subacute  in  char- 
acter. They  are  neuralgic  pain  in  the  limb,  "  sciatic  rheumatism," 
stiffness  on  changing  from  rest  to  activity,  and  sensitiveness  to 
direct  pressure  on  the  joint,  so  that  the  patient  often  lies  habitu- 
ally on  the  other  side.  The  movements  of  the  joint  become 
somewhat  restricted,  and  in  certain  instances  creaking  sounds 
are  apparent  to  the  patient.  In  the  advanced  stages  of  the  dis- 
ease there  is  marked  thickening  about  the  trochanter  which  is 
usually  displaced  upward,  owing  to  the  progressive  changes  in 
the  head  and  neck  of  the  femur.  The  limb  is  shortened  and  it  is 
often  distorted,  usually  in  an  attitude  of  flexion  and  adduction, 
and  marked  atrophy  is  apparent.  These  symptoms,  but  for  the 
history,  might  be  mistaken  for  the  results  of  fracture  of  the  neck 
of  the  femur,  and  in  the  earlier  period  of  the  disease  the  limp, 
the  pain,  and  restriction  of  motion  with  the  attendant  atrophy 
may  simulate  very  closely  tuberculous  disease  of  a  subacute 
type. 

The  progress  of  the  disease  may  be  slow  or  it  may  be  rapid. 
It  depends  in  great  degree  upon  the  strain  to  which  the  part  is 
subjected.     In  this  it  resembles  tuberculous  disease. 

Treatment.  In  the  class  of  cases  in  which  the  disease  is  con- 
fined to  a  single  joint  one  may  hope  to  check  the  progress  of  the 
destructive  process  by  lessening  the  strain  upon  the  joint  by 
regulation  of  the  patient's  habits  and  occupation,  and  to  improve 
the  nutrition  of  the  part  by  massage  and  local  stimulants. 
Passive  motion  in  the  directions  of  abduction  and  extension  for 
the  purpose  of  preventing  secondary  contraction  of  the  muscles, 
is  of  service  also. 

If  deformity  be  present  it  should  be  reduced  by  traction  and 
rest  in  bed.  Afterward  the  symptoms  may  be  relieved  by  the 
use  of  a  hip  brace  (Fig.  231)  that  will  remove  the  weight  and 
limit  the  range  of  motion,  or  a  support  of  the  character  of 
a  Lorenz  spica  of  plaster,  leather,  or  other  material  may  be 
used.  In  extreme  cases  resection  of  the  upper  extremity  of  the 
femur  might  be  advisable.      Lorenz  states  that  he  has  treated 


398  ORTHOPEDIC  S  UR GER  Y. 

cases  satisfactorily  by  inducing  anterior  transposition  of  the 
head  of  the  femur  and  fixing  the  limb  for  a  time  in  an  attitude 
of  extension  and  abduction.  In  most  cases  neither  the  operative 
nor  the  brace  treatment  is  feasible,  but  the  use  of  a  firm  flannel 
spica  bandage  or  similar  support,  combined  with  the  application 
of  cautery,  from  time  to  time,  adds  to  the  comfort  of  the  patient. 


CHAPTER   IX 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


Fig.  244. 


Synonyms.     White  swelling,  tumor  albus. 

Tuberculous  disease  of  the  knee-joint  is  next  in  frequency  and 
importance  to  that  of  the  hip.  It  is,  however,  far  less  dangerous 
to  life,  and  the  prognosis,  as  regards  function,  is  much  better  than 
in  the  former  affection.  This  is  explained  by  the  simplicity  of 
the  joint  and  by  its  situation  at  a  distance  from  the  trunk,  at  the 
junction  of  two  levers  of  nearly  equal  length  and  size.  As  the 
problem  of  protection  by  mechanical  means 
is  comparatively  simple  it  is  more  often 
applied,  and  in  proportion  to  its  efficiency 
the  injury  of  functional  use  is  lessened 
and  the  tendency  to  deformity  is  checked. 

Pathology.  The  disease  may  begin  in 
the  epiphysis  of  the  femur  or  in  that  of 
the  tibia,  occasionally  in  the  patella  or  in 
the  head  of  the  fibula,  or  primarily  in  the 
synovial  membrane. 

In  547  cases,^  about  two-thirds  of  which 
were  in  adults,  treated  at  Koenig's  clinic 
at  Gottingen  by  operative  procedures 
which  permitted  inspection  of  the  joint, 
281  (51.4  per  cent.)  were  apparently  ex- 
amples of  primary  osteal  disease  ;  266 
(48.6  per  cent.)  were  primarily  synovial. 
The  focus  was  in  the  femur  in  93  in- 
stances (33.1  per  cent.),  in  the  tibia  in 
107  (38.1  per  cent.),  in  the  patella  in  33 
(11.7  per  cent.),  and  in  more  than  bone 
in  48  (17.1  per  cent.). 

The  examination  of  a  joint  permitted  by  arthrectomy  or  excision 
cannot  be  sufficiently  thorough  to  exclude  disease  of  the  bone  and 
to  establi.sh  the  diagnosis  of  primary  disease  of  the  synovial  mem- 


Section  of  knee-joint  at  the 
age  of  eight  years,  showing 
the  epiphyses  of  the  femur  and 
tibia  and  their  relation  to  the 
capsule.  (Krause.)  The  centres 
of  ossification  in  the  epiphyses 
of  the  femur  and  tibia  are 
present  at  birth.  Ossification 
is  completed  in  each  at  about 
the  twentieth  year. 


1  Die  Specielle  Tubercnlose  der  Knocken  und  Gelenke,  Berlin,  1896. 


400  OB  THOPEDIC  SUBGER  Y. 

brane,  but  in  92  instances  the  opportunity  was  offered  by  ampu- 
tation at  the  thigh,  80  of  the  patients  being  adults.  This 
examination,  presumably  thorough,  showed  the  primary  disease 
to  be  of  the  bone  in  50  cases,  while  in  35  the  synovial  membrane 
was  apparently  the  seat  of  the  primary  affection. 

In  17  of  the  50  cases  in  which  the  disease  was  osteal,  the  focus 
was  in  the  femur  ;  in  7  it  was  in  the  internal  condyle,  in  6  in 
the  external  condyle,  and  it  was  in  other  situations  in  4  cases. 
In  17  the  primary  disease  was  of  the  tibia  ;  in  5  of  the  internal 
tuberosity  ;  in  5  of  the  external  tuberosity  ;  in  other  situations  7. 
In  5  instances  the  primary  disease  was  of  the  patella,  and  more 
than  one  bone  was  involved  in  1 1  cases.  Nichols'  states  that  he 
has  examined  120  tuberculous  joints  of  adults  and  children,  after 
excision  or  amputation,  or  at  autopsy,  and  in  every  instance  pri- 
mary foci  in  the  bone  were  discovered.  He  believes  primary  disease 
of  the  synovial  membrane  to  be  very  uncommon,  and  asserts  that 
examinations  are  of  no  particular  value  as  establishing  the  absence 
of  primary  osteal  disease  unless  the  bones  are  sawed  into  thin 
sections.  This  is  the  view  generally  held  in  this  country,  that  in 
the  great  majority  of  cases  the  disease  of  the  bone  precedes  the 
disease  in  the  interior  of  the  joint.  From  the  clinical  standpoint, 
however,  one  recognizes  two  distinct  types  of  tuberculous  dis- 
ease :  one,  beginning  as  a  chronic  synovitis  of  which  the  early 
symptoms  are  subacute,  a  type  more  often  seen  in  adults  (Fig. 
248)  ;  and  the  more  common  class,  in  which  the  symptoms  of 
pain,  muscular  spasm,  and  deformity  seem  to  indicate  clearly 
primary  disease  of  the  bone. 

The  proximity  of  the  active  disease  in  the  neighborhood  of  the 
joint  sets  up  a  sympathetic  hypersemia  within  it,  and  an  accom- 
panying synovitis.  If  the  disease  is  progressive  the  synovial 
membrane  becomes  thickened  and  adhesions  form  between  its 
folds  that  gradually  lessen  the  capacity  of  the  joint  and  diminish 
its  mobility.  When  perforation  takes  place  the  granulation 
tissue  spreads  over  the  surface  of  the  cartilages,  destroying  them 
in  its  progress  and  eroding  the  underlying  bone ;  or  if  the  joint 
is  filled  with  tuberculous  fluid  the  cartilage  may  be  macerated  and 
separated  in  necrotic  shreds.  The  direct  destructive  effects  of  the 
disease  are  increased  by  pressure  and  friction  if  the  joint  is  not 
protected  by  mechanical  means.  The  hypertrophied  synovial  mem- 
brane and  the  thickened  and  diseased  capsule  explain  the  peculiar 

1  Transactions  American  Orthopedic  Association,  vol.  xi. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.       401 

elastic  resistance  on  palpation  called  pseudofluctuation.  In  more 
advanced  cases  there  is  also  a  reactive  inflammation  in  the  over- 
lying tissues,  accompanied  by  a  formation  of  fibrous  tissue  that 
involves  the  tendons  and  muscles.  These  changes  within  and 
without  the  joint  cause  the  firm,  resistant  tumor  characteristic  of 
"  white  swelling." 

Pig.  245. 


Flexion  deformity  at  the  knee-joint,  with  slight  subluxation  of  the  tibia. 

Etiology.  The  etiology  of  tuberculous  disease  has  been  dis- 
cussed in  Chapters  V.  and  VII. 

Statistics.  Tuberculosis  of  the  knee-joint  is  essentially  a  dis- 
ease of  early  life,  although  it  is  less  strictly  confined  to  childhood 
than  is  disease  of  the  spine  or  hip.     Sex   exercises  but  little 


Fig.  246. 


After  forcible  correction,  showing  the  increase  of  the  posterior  displacement, 
from  the  X-ray  photographs  of  an  actual  case. 


Drawings 


influence,  and  the  two  sides  are  affected  in  nearly  equal  numbers. 
These  points  are  illustrated  by  the  following  table  of  1000  con- 
secutive cases  treated  at  the  Hospital  for  Ruptured  and  Crippled.^ 

'  These  statistics,  together  with  those  of  tuberculous  disease  of  the  joints,  other  than  of  the 
hip,  were  collected  for  rae  by  Drs.  F.  C.  Bradner,  S,  E,  Sprague,  E.  L.  Barnett,  and  S.  W. 
Stone,  house  officers  at  the  hospital,  1900-1901. 

26 


402 


ORTHOPEDIC  SUBGEBY. 


Age  at  Incipiency  of  Kkee-joint  Disease. 


year  or  less      .       .       .       .25 
years  old 45 


I 

2 

3 

4 

5 

6 

7 

8 

9 
10 
U 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 

Males 512 

Females 


23  years  old 12 


45 

24   " 

91 

25   " 

164 

26   " 

84 

27   " 

75 

28   " 

66 

29   " 

74 

30   " 

65 

31   " 

60 

32   " 

46 

33   " 

20 

34   " 

19 

35   " 

17 

36   " 

12 

37   " 

10 

38   " 

20 

39   " 

8 

40   " 

8 

41   " 

8 

50   '• 

12 

13 

512 

Right 

488 

Left  . 

485 
515 


Symptoms.  The  general  characteristics  of  tuberculosis  have 
been  described  in  the  chapters  on  Pott's  disease  and  hip  disease. 
In  the  description  of  these  affections,  however,  but  little  stress 
was  laid  on  local  sensitiveness  and  local  swelling,  because  the 
diseased  parts  lie  at  a  distance  from  the  surface  and  are  concealed 
by  the  muscles  and  other  tissues.  At  the  knee,  on  the  other 
hand,  the  joint  is  superficial,  and  even  slight  effusion  changes, 
to  a  perceptible  degree,  its  contour.  If  the  disease  is  progres- 
sive sensitiveness  to  pressure,  elevation  of  the  local  temperature, 
and  infiltration  or  thickening  of  the  tissues  are  usually  present. 

Even  when  the  patients  are  seen  at  a  comparatively  early  stage 
in  the  course  of  the  disease  the  history  of  the  affection  will  almost 
always  show  that  it  is  chronic  and  progressive  in  character.  The 
importance  of  establishing  this  fact  has  been  mentioned  in  the 
consideration  of  hip  disease,  and  it  may  be  stated  again  that  a 
chronic  painful  disease  of  a  single  joint,  accompanied  by  a  ten- 
dency to  deformity,  is,  in  childhood,  almost  always  tuberculous 
in  character. 

The  symptoms  of  tuberculous  disease  may  be  classified  as 
limp,  pain,  local  heat,  sensitiveness  and  swelling,  muscular  spasm 
and  limitation  of  motion,  distortion  and  atrophy. 

On  physical  examination  one  will  note  the  character  of  the 
limp  and  the  slight  flexion  of  the  limb  that  usually  accompanies 
it.     The  joint  is,  as  a  rule,  somewhat  enlarged,  and  the  normal 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT. 


403 


depressions  about  the  patella  and  the  projection  of  the  component 
bones  are  less  accentuated  than  on  the  opposite  side.  There  is 
usually  slight  local  elevation  of  temperature  and  sensitiveness  to 
pressure,  varying  in  degree  with  the  character  of  the  disease. 
In  certain  cases  a  degree  of  effusion  is  present,  sufficient  to  be 
classed  as  synovitis,  but  in  most  instances  the  swelling  is  due,  in 
great  part,  to  the  hypersemia  and  thickening  of    the  synovial 


Acute  tuberculous  arthritis  of  the  knee. 


membrane  and  the  capsule,  which  gives  the  sensation  of  elastic 
resistance  rather  than  of  actual  fluctuation. 

The  most  important  diagnostic  sign  is  limitation  of  the  range 
of  motion  caused  by  muscular  spasm.  The  normal  range  is  from 
complete  extension,  180  degrees,  to  a  degree  of  flexion,  limited  by 
the  apposition  of  the  calf  and  the  posterior  surface  of  the  thigh. 
Even  in  the  early  stage  of  disease  slight  limitation  of  complete 


404  ORTHOPEDIC  S UJR OER  Y. 

extension  is  present,  due  to  reflex  muscular  spasm,  and  usually  a 
corresponding  limitation  of  the  complete  flexion.  On  sudden 
movements  the  characteristic  reflex  contraction  of  the  muscles  is 
apparent.  In  most  cases  this  limitation  of  motion  and  consequent 
flexion  deformity  is  well  marked  on  the  first  examination. 
Atrophy  of  the  muscles  of  the  thigh  and  calf,  dependent  upon 
the  duration  of  the  disease  and  upon  the  interference  with  func- 
tion, is  present,  and  this  atrophy  is  more  noticeable  because  of 
the  enlargement  of  the  knee. 

In  certain  cases,  more  often  seen  in  infancy  and  early  child- 
hood, the  symptoms  are  more  acute  and  the  progress  of  the 
disease  is  so  rapid  that  it  may  simulate  an  infectious  epiphysitis 
(Fig.  247). 

In  another  type,  apparently  a  primary  disease  of  the  synovial 
membrane,  more  common  in  adults,  the  early  symptoms  are 
very  similar  to  those  of  simple  chronic  synovitis.  The  joint  is 
swollen  by  a  distention  of  the  capsule,  pain  is  not  troublesome 
except  on  jars  or  sudden  twists  of  the  limb,  and  muscular  spasm 
and  limitation  of  motion  are  evident  only  after  a  careful  exam- 
ination. In  this  class,  months  or  years  may  pass  before  the 
symptoms  become  as  disabling  as  in  the  osteal  type  of  the  disease. 

Primary  and  Secondary  Distortions  of  Knee-joint  Disease.  At  the 
hip-joint,  in  which  the  range  of  motion  is  extensive,  the  deform- 
ities resulting  from  disease  are  somewhat  complex,  causing,  for 
example,  apparent  shortening  or  lengthening,  according  as  the 
limb  is  adducted  or  abducted.  But  the  movements  that  the 
knee-joint  permits  are  much  simpler,  and  the  primary  distortion 
is  simply  flexion.  Complete  extension  of  the  limb,  the  limit  of 
normal  motion  in  that  direction,  brings  the  joint  surfaces  into 
close  apposition  ;  the  ligaments  are  then  tense  and  no  lateral 
motion  is  permitted.  This  is  the  attitude  in  which  the  greatest 
efficiency  of  the  limb  for  weight  bearing  is  assured.  When  the 
ability  of  the  knee  for  carrying  out  its  normal  weight-bearing 
function  is  lessened  by  disease  which  makes  the  parts  sensitive 
to  pressure  and  strain,  the  range  of  extension  is  lessened  and  the 
limb  is  persistently  flexed  to  a  greater  or  less  degree,  correspond- 
ing to  the  sensitiveness  of  the  joint.  The  agents  that  adapt  the 
limb  to  the  habitual  attitudes  are  the  muscles  under  the  control  of 
the  nervous  system.  In  this  sense  the  primary  distortions  are 
due  to  muscular  action,  but  it  is  certainly  not  true  that  these 
muscles  antagonize  one  another,  and  that  the  stronger  over- 
coming the  weaker  cause  the  deformity,  since  the  extensors  at 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        405 


Fig.  248. 


this  joint  are  stronger  than  the  flexors,  and  since  flexion  is  the 
primary  deformity  at  every  joint  which  is  diseased  without  regard 
to  the  relative  strength  of  the  opposing  muscular  groups. 

In  disease  at  the  kuee-joiut,  as  at  other  joints,  the  extremes  of 
motion  in  every  direction  that  the  joint  permits  are  limited  by 
muscular  spasm,  but  limitation 
of  extension,  which  is  so  essential 
to  normal  use,  is  at  once  evident, 
while  limitation  of  flexion,  the 
extreme  of  which  is  unessen- 
tial, is  only  apparent  on  examina- 
tion, and  it  may  be  absent  even. 
Flexion  is,  then,  the  primary  dis- 
tortion at  the  knee,  and  other 
deformities  may  be  classed  as 
secondary. 

Secondary  Deformities.  Of  these 
the  most  common  is  outward 
rotation  of  the  tibia  upon  the 
femur.  When  the  limb  is  fully 
extended  there  is  no  lateral  mo- 
tion at  the  knee,  but  when  it  is 
flexed  lateral  motion  is  possible, 
and  in  the  attitude  of  flexion 
the  traction  of  the  biceps  upon 
the  head  of  the  fibula  tends  to 
rotate  it  upon  the  femur.  This 
deformity  is  also  favored  by  the 
use  of  the  limb  in  the  attitude 

of  outward  rotation,  which  is  always  assumed  when  the  weakness 
or  stiffness  of  the  knee-joint  is  present,  and  by  the  secondary 
knock-knee  that  often  accompanies  the  disease. 

Subluxation  or  backward  displacement  of  the  tibia  upon  the 
femur  is  another  secondary  deformity.  When  the  leg  is  flexed 
upon  the  thigh  the  articulating  surface  of  the  tibia  glides  back- 
ward upon  the  condyles  of  the  femur.  Here  it  becomes  fixed  by 
muscular  contraction,  and  later  by  the  secondary  changes  within 
the  joint.  If  muscular  spasm  be  extreme  this  alone  might  cause 
the  subluxation,  but  there  are  other  factors  ;  one  is  the  destruc- 
tive action  of  the  disease,  which  is  usually  most  marked  at  the 
point  at  which  the  bones  are  in  contact,  aud  the  other  is 
the  leverage  exerted  upon  the  joint.     This  is  exemplified  by  the 


Tuberculous  disease  of  the  knee  in  an 
adult.    The  synovial  type. 


406 


ORTHOPEDIC  SURGERY. 


increase  of  the  displacement  that  is  often  observed  when  an 
attempt  is  made  to  straighten  the  limb  by  force,  against  the 
resistance  offered  by  the  contracted  tissues  on  the  flexor  aspect. 
The  same  leverage,  in  slighter  degree,  is  exerted  when  the  weight 


Fig.  249. 


Untreated  disease  of  the  knee-joint  involving  the  shaft  of  the  femur,  illustrating  the 
hypertrophy  of  the  condyles  of  the  femur,  the  subluxation  and  outward  rotation  of  the 
tibia,  the  atrophy  and  the  characteristic  deformity. 


of  the  distorted  limb  is  supported  on  the  heel  in  the  recumbent 
posture,  or  when  the  limb  is  extended  in  the  act  of  walking,  or  if 
the  upper  extremity  of  the  tibia  is  not  supported  during  the 
period  of  treatment  by  apparatus  (Fig.  246). 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.       407 

Knock-knee  (genu  valgum)  is  another  secondary  deformity. 
This  is  explained  in  certain  instances  by  the  hypertrophy  of  the 
internal  condyle  caused  by  disease,  but  it  is  induced  more  directly 
by  the  use  of  the  flexed  and  somewhat  disabled  limb  in  the  pas- 
sive attitude  of  outward  rotation.  Genu  varum  is  uncommon, 
and  it  is  usually  the  result  of  the  destruction  of  a  part  of  the 
internal  condyle  of  the  femur  or  of  the  tibia,  or  of  irregular 
epiphyseal  growth. 

The  character  and  the  relative  frequency  of  the  deformities  are 
indicated  by  the  statistics  of  Koenig's^  clinic,  of  150  cases  of  knee- 
joint  disease  treated  by  arthrectomy,  128  of  these  being  in  children. 
In  94  cases  flexion  was  present ;  in  50,  from  a  slight  degree  to 
135  degrees  ;  in  16,  from  135  degrees  to  90  ;  in  28,  to  a  right 
angle  or  less.  Together  with  the  flexion  were  combined  other 
deformities  as  follows  :  Genu  valgum  in  60  cases ;  moderate  in 
42;  extreme  in  18.  Genu  varum  in  1  case.  Subluxation  of 
the  tibia  in  20  cases.     Outward  rotation  of  the  tibia  in  10  cases. 

As  has  been  stated,  the  primary  deformity  of  knee  disease  is 
simple  flexion.  If  the  disease  is  of  an  acute  type  this  flexion 
increases  rapidly.  If  it  is  subacute  in  character,  and  especially 
if  the  clinical  signs  indicate  that  the  disease  is  primarily  of  the 
synovial  membrane,  the  progress  of  the  deformity  is  slow.  In 
ordinary  cases  secondary  deformities  appear  at  a  later  time  and 
especially  when  the  disease  has  reached  the  destructive  stage  ; 
and  they  are  most  marked  in  patients  who  have  persistently  used 
the  deformed  limb  without  protection. 

Actual  Shortening  and  Actual  Lengthening.  Retardation  of 
growth  is,  of  course,  not  an  early  symptom  of  disease ;  in  fact, 
actual  lengthening  of  the  limb,  due  to  the  irritative  effect  of  the 
disease  upon  the  epiphyseal  cartilage  of  the  femur  or  of  the  tibia, 
is  common.  This  lengthening,  sometimes  to  the  extent  of  an 
inch  or  even  more,  may  persist  throughout  the  entire  course  of 
treatment,  but  after  the  cure  of  the  disease  a  corresponding 
retardation  of  growth  that  will  more  than  equalize  the  length  of 
the  limbs,  may  be  expected.  When  the  disease  is  of  the  destruc- 
tive type  the  ultimate  shortening  may  be  considerable;  two  or 
more  inches  is  not  unusual. 

Leusden,^  in  33  cases  under  treatment  in  the  clinic  at  Got- 
tingen,  1896-1898,  found  slight  shortenting  in  2,  equality  of 
length  in  18,  lengthening  of  the  femur  on  the  diseased  side  in  13. 

1  Log.  clt.  -  Deutsche  Zeila.  f.  Chir.,  Bd.  li.  H.  3  and  4. 


408  ORTHOPEDIC  SUBOEBY. 

In  one  hundred  and  sixteen  cases  of  tuberculous  disease  of  the 
knee  the  limbs  were  measured  by  Berry  and  Gibney^  with  refer- 
ence to  this  point.  In  72  of  these  there  was  actual  lengthening 
of  the  femur,  from  which  in  may  be  inferred  that  in  at  least 
62  per  cent,  of  the  cases  examined  the  primary  disease  was  of 
the  femur. 

In  17 i^  inch. 

"34 i<    " 

"15 %    " 

"6 1    " 

72  =  62  per  cent. 

H.  L.  Taylor,^  from  an  examination  of  40  cases  of  tuberculous 
disease  of  the  knee,  concludes  that  the  limb  is  almost  always 
longer  in  the  first  two  years  of  the  disease,  usually  longer  during 
the  second  two  years,  but  usually  shorter  when  the  period  of 
growth  is  completed.  The  lengthening  is  in  most  instances  of 
the  femur. 

Diagnosis.  Tuberculous  disease  is  a  local  destructive  process 
that  is,  as  a  rule,  confined  to  a  single  joint.  This  is  an  important 
point  in  the  differential  diagnosis  from  general  or  constitutional 
affections  like  rheumatism,  rheumatoid  arthritis,  and  the  like,  in 
which  several  joints  are  involved.  The  following  affections  may 
be  considered  in  differential  diagnosis. 

Injury  of  the  Knee.  Strains  of  the  knee  in  childhood  are  often 
followed  by  limp  and  persistent  flexion  and  pain  on  motion.  In 
such  cases  the  onset  is  sudden  and  the  symptoms  usually  disap- 
pear quickly  under  treatment.  Synovitis  of  traumatic  origin  is 
usually  indicative  of  a  more  severe  injury.  When  synovitis  per- 
sists the  diagnosis  may  be  doubtful  because  tuberculous  infection 
may  have  followed  the  original  injury.  This  emphasizes  the 
importance  of  the  careful  treatment  and  continued  observation  of 
injuries  of  this  class,  especially  iu  weakly  children. 

Synovitis.  Chronic  synovitis  of  doubtful  origin,  which  shows 
no  tendency  toward  recovery,  is  usually  tuberculous  in  character. 

Haemophilia.  Eff'usion  of  blood  into  the  knee-joint  may  cause 
inflammatory  symptoms  during  the  stage  of  absorption  and 
organization  of  the  clot  that  resemble  those  of  disease.  The 
sudden  onset  and  the  personal  history  of  the  patient,  who  may 
be  known  as  a  bleeder,  will  explain  the  symptoms.  (See  page 
283.) 

1  American  Journal  of  the  Medical  Sciences,  October,  1893. 

2  Transactions  American  Orthopedic  Association,  1901,  yoI.  xiv. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.       409 

Infectious  Arthritis — Acute  Epiphysitis.  This  is  of  sudden 
onset,  attended  by  the  constitutional  and  local  symptoms  of  acute 
infection. 

Rheumatism.  This,  in  early  childhood,  may  be  confined  to  a 
single  joint,  but  it  is  of  sudden  onset,  it  is  usually  accompanied 
by  constitutional  disturbance,  and  after  a  time  other  joints  become 
involved. 

Rheumatoid  Arthritis — Osteoarthritis.  Diseases  of  this  char- 
acter, of  the  monarticular  form,  are  more  common  in  adult  life. 
The  symptoms  are  rather  of  the  rheumatic  than  of  the  tuber- 
culons  type. 

Charcot's  Disease.  Charcot's  disease  of  the  knee-joint  is  char- 
acterized by  sudden  effusion,  by  rapid  destruction  of  the  joint, 
and  consequently  by  weakness  and  deformity  ;  but  pain  is  usually 
very  slight  and  muscular  spasm  is  absent.  The  diagnosis  of  dis- 
ease of  the  spinal  cord  will  explain  the  condition  of  the  joint. 
(See  page  284.) 

Sarcoma.  Sarcoma,  beginning  in  or  near  the  epiphysis  of  the 
femur  or  of  the  tibia,  may  simulate  tuberculous  disease  very 
closely.  If  the  tumor  is  of  the  periosteal  type,  it  usually  forms 
a  more  localized  and  irregular  swelling  than  could  be  accounted 
for  by  tuberculous  disease.  Central  sarcoma  may  simulate  tuber- 
culous disease  also,  but  the  progress  of  the  tumor  is  more  rapid. 
The  clinical  distinction  between  the  two  is  that  tuberculous  dis- 
ease is  very  amenable  to  treatment  as  far  as  its  symptoms  are 
concerned,  while  the  progress  of  sarcoma  is  but  little  influenced 
by  treatment.  It  may  be  stated,  however,  that  the  X-ray  is  the 
only  means  of  early  diagnosis,  the  destruction  of  the  substance 
of  the  bone  about  the  tumor  being  much  greater  than  that  caused 
by  the  tuberculous  process. 

Hysterical  Joint.  Some  of  the  symptoms  of  disease  may  be 
simulated  by  hysterical  subjects,  but  there  is  always  an  absence 
of  the  positive  physical  signs  that  invariably  accompany  a 
destructive  disease.  These  and  other  affections  are  described  at 
length  in  the  following  chapters. 

Treatment.  The  treatment  of  tuberculous  disease  of  the  knee 
in  childhood  is  conservative,  operative  intervention  being  simply 
incidental  to  protective  treatment.  In  adult  life,  on  the  other 
hand,  the  radical  removal  of  the  disease  may  be  indicated  as  the 
primary  measure.  The  reasons  for  this  distinction  are  obvious. 
In  childhood  the  duration  of  treatment  is  of  no  particular  impor- 
tance as  compared  with  the  final  functional  result,  but  in  adult 


410 


ORTHOPEDIC  SURGERY. 


life  the  shortening  of  the  period  of  disability  and  the  definite 
assurance  of  cure  may  be  of  far  greater  moment  than  the  preser- 
vation of  motion. 

In  childhood,  under  favorable  conditions,  ultimate  recovery,  with 
fair  functional  use  of  the  joint,  may  be  anticipated;  while  a  radical 
operation,  although  it  may  cure  the  patient  in  a  shorter  time, 
takes  away  the  possibility  of  a  cure  with  motion.  In  adult  life  a 
rigid  limb  is  a  strong,  useful,  if  somewhat  awkward  support,  but 
in  childhood  '  the  removal  of  portions  of  the  epiphyses  and  of  the 
epiphyseal  cartilages  entails  a  progressive  inequality  in  the  limbs, 
due  to  loss  of  growth,  and  unless  the  limb  is  protected  by  mechan- 
ical means  deformity  is  the  rule,  even  though  the  disease  has  been 
thoroughly  removed.  Thus  the  treatment  of  routme  is,  in  child- 
hood,   at  least,    protection ;   protection  from  the  traumatism  -of 


Fig.  250. 


Extension  and  counter-extension  in  disease  of  the  knee-joint.    (Marsh.) 


motion,  from  the  shock  of  impact  with  the  ground,  and  from  the 
pressure  of  muscular  spasm  and  contraction. 

Mechanical  treatment,  which  is  so  difficult  at  the  hip,  is  com- 
paratively easy  at  the  knee,  and,  as  has  been  stated,  the  results 
are  correspondingly  better.  At  the  hip-joint  one  of  the  most 
common  causes  of  shortening  and  deformity  is  upward  displace- 
ment of  the  femur  upon  the  pelvis,  but  at  the  knee,  if  the  limb  is 
supported  in  the  attitude  of  extension,  the  apposition  of  the  broad 
surfaces  of  the  femur  and  the  tibia  prevents  displacement,  while 
muscular  spasm,  a  symptom  whose  intensity  is  in  proportion  to 
the  degree  of  harmful  motion  that  is  permitted,  is  easily  controlled 
by  efficient  splinting. 

Reduction  of  Deformity.  The  first  step  in  treatment  is  the 
reduction  of  deformity  that  may  be  present,  in  order  that  the 
limb,  at  the  beginning  as  well  as  throughout  the  entire  course  of 
treatment,  may  be  in  absolute  normal  position  ;  and  as  the  chief 
function  of  the  leg  is  to  support  weight  the  proper  attitude  is 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        411 

complete  extension.  Whatever  motion  the  patient  retains  will 
then  be  about  the  point  of  greatest  usefulness.  In  the  cases  in 
which  an  opportunity  for  reasonably  early  treatment  is  offered 
the  only  deformity  is  flexion,  induced  by  muscular  contraction, 
although  if  it  has  persisted  for  some  time  secondary  retraction  of 
the  muscles  may  be  present.  In  this  class  of  cases  the  spasm, 
and  consequently  the  deformity,  may  be  readily  overcome  by 
placing  the  joint  at  rest. 

Fig.  251. 


Tuberculous  disease  of  the  knee  in  an  adult,  witli  the  form  of  Billroth  splint  used 
at  the  Hospital  for  Ruptured  and  Crippled. 

The  Plaster  Bandage.  The  most  efficient  splint  for  this  purpose 
is  a  close-fitting  plaster  bandage,  applied  from  the  groin  to  the 
ankle,  or,  better,  to  include  the  foot,  in  order  to  prevent  oedema 
of  the  unsupported  part,  which  is  common  after  the  first  dressing 
and  until  the  circulation  of  the  limb  has  become  adapted  to  the 
new  conditions.  In  the  application  of  the  bandage  the  bony 
prominences  of  the  knee  and  ankle  are  protected  by  cotton.  A 
canton-flannel  bandage  is  then  applied  smoothly,  and  directly 
upon  this  the  light  plaster  bandage.     At  tlie  second  application. 


412  ORTHOPEDIC  SURGERY. 

at  the  end  of  a  week,  the  subsidence  of  the  spasm  will  permit  the 
straightening  of  the  limb.  In  cases  of  longer  standing  several 
successive  applications  of  the  bandage  may  be  required,  together 
with  manual  extension  during  the  application ;  or  an  anaesthetic  may 
be  administered.  Under  anaesthesia  the  muscular  spasm  relaxes 
and  deformity,  even  of  some  standing,  may  be  reduced  by  traction 
and  by  slight  leverage,  the  head  of  the  tibia  being  supported  and 
drawn  forward  by  the  hands  as  the  deformity  is  gently  reduced. 

Traction.  Deformity  may  be  reduced  also  by  traction  with 
the  weight  and  pulley,  the  leg  being  supported  so  that  no  direct 
leverage  is  exerted  at  the  seat  of  the  disease  (Fig.  250). 

Forcible  Correction  by  Reverse  Leverage.  In  the  more  resistant 
cases,  especially  if  accompanied  by  subluxation,  the  following 
method  may  be  employed :  The  patient  is  anaesthetized  and  is 
placed  face  downward  on  a  table,  the  feet  projecting  over  its  end. 

Fig.  252. 


Illustrating  the  method  of  supporting  the  body  and  fixing  the  tihia  before  straightening 
the  limb.  The  folded  sheet  indicates  the  degree  of  subluxation  present.  In  resistant  cases 
of  this  type  an  assistant  applies  the  pressure  on  the  thigh 

The  body  of  the  patient  is  then  elevated  by  means  of  pillows  to 
conform  to  the  deformity — that  is,  the  thigh  of  the  affected  limb 
is  raised  sufficiently  to  allow  the  tibia  to  lie  evenly  upon  its  an- 
terior border  on  the  table.  The  operator  with  one  hand  holds 
the  head  of  the  tibia  firmly  against  the  table  and  with  the  other 
massages  the  contracted  tissues  of  the  popliteal  region,  gradually 
exerting  more  downward  pressure  on  the  thigh,  but  never  to  the 
extent  to  lift  the  tibia  from  the  table  ;  thus,  further  subluxation 
is  impossible.  As  the  contraction  gives  way  the  pillows  are 
removed.  Usually  the  deformity  may  be  reduced  at  one  sitting, 
but  if  it  is  very  resistant  complete  correction  is  not  attempted.  At 
the  conclusion  of  the  operation  adhesive  plaster  straps  for  traction 
and  a  close-fitting  plaster  bandage  are  applied  (Fig.  252). 


Fig.  253. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        413 

Rest  in  bed  with  traction  is  enforced  for  a  time,  and  the  ordi- 
nary brace  is  then  employed.  This  is,  in  the  author's  experience, 
the  most  effective  and  satisfactory  method  for  reducing  deformity. 
If  the  contraction  is  of  long  standing  preliminary  division  of  the 
flexor  tendons  may  be  advisable,  but  this  is  not  usually  necessary.^ 

The  Billroth  Splint.  The  Billroth  splint,  as  modified  by  Still- 
man,  is  an  effective  appliance  for  overcoming  resistant  deformity. 
A  thick  pad  of  felt  is  placed  over  the 
upper  surface  of  the  condyles  of  the 
femur  and  a  thinner  pad  in  the 
popliteal  region  over  the  upper  bor- 
der of  the  tibia.  Other  points  that 
may  be  subjected  to  pressure  are 
similarly  protected,  especially  the 
dorsum  of  the  foot  and  the  perineum. 
A  plaster  bandage  is  then  applied 
from  the  groin  to  the  toes,  made 
especially  thick  and  strong  in  the 
popliteal  region.  On  either  side  of 
the  knee  two  curved,  slotted  steel 
bars  attached  to  expanded  tin  splints 
and  joined  to  one  another  by  an 
adjustable  bolt  are  incorporated  in 
it  (Fig.  251).  When  the  bandage 
hardens  it  is  completely  divided  into 
two  parts  by  a  circular  cut  about  the 

knep  and  the  bolts  in  the  slots  are  '^^^  Brad  ford-Gold  th  wait  genuclast 
Knee,   ana  tne    DOUS    m    Uie  SIOIS  aie    for  the  correction  of  flexion  deformity 

so  adjusted  as  to  form  a  hinged  splint,    and  subluxation  at  the  knee.  Counter- 

„  .        ,     .  ,  pressure  is  applied  over  the  lower  ex- 

the  centre  Ot  motion  bemg  somewhat    tremity  of  the  femur,     subluxation  is 

above  and  in  front  of  the  knee-joint,   fve^f^ed  during  the  forcible  correc- 

^  J  tion  by  means  of  the  screw  and  strap 

When  the    limb  is   slightly  extended    beneath  the  head  of  the  tlWa,  by  wWch 
.  .   .  c     ,  1         1  •  1  it  is  drawn  forward. 

the    position   or    the    hinges    has    a 

tendency  to  lift  the  tibia  and  to  separate  it  from  the  femur. 
This  straightening  opens  the  cut  in  the  popliteal  region,  which 
is  held  open  by  a  wedge  of  cork.  In  this  manner,  by  the  in- 
sertion of  larger  wedges,  the  limb  is  gradually  straightened  from 
day  to  day  until  the  deformity  is  overcome,  or  until  a  new  band- 
age is  required.  If  the  pressure  on  the  front  of  the  femur, 
when  the  leverage  is  exerted,  becomes  painful,  a  part  of  the  pad- 
ding is  removed. 


'  Whitman.    American  .Tournal  of  the  Medical  Sciences,  May,  1903. 


414 


OB THOPEDIC  SUBOEB  Y. 


In  the  treatment  of  older  subjects  greater  force  may  be  em- 
ployed by  means  of  osteoclasts.  One  of  the  best  machines  of  this 
type  is  the  Bradford-Goldthwait  genuelast  (Fig.  253).  The  more 
violent  methods  should  not  be  employed  during  the  active  stages 
of  the  disease;  and  whenever  considerable  force  is  required  in 
young  subjects  the  possibility  of  separating  the  epiphysis  of  the 
femur,  forcing  it  backward,  and  thus  pressing  upon  the  popliteal 
vessels,  should  be  borne  in  mind. 

Mechanical  Treatment.  The  most  efficient  mechanical  appliance 
for  the  treatment  of  tuberculous  disease  at  the  knee  is  the  Thomas 


Fig.  254. 


Fig.  255. 


The  Thomas  knee-splint,  showing  the 
inner  bar  B  placed  farther  to  the  front 
than  the  outer  bar  C;  A  is  the  lowest 
part  of  the^ring ;  upon  this  rests  the  tuber- 
osity of  the  ischium. 


The  ring  of  the  Thomas  knee-splint  after 
padding.    (Ridlon.) 


hnee  brace.  This  consists  of  two  lateral  uprights  which  support 
the  limb  on  either  side,  terminating  below  the  foot  in  a  crossbar 
shod  with  leather  or  rubber,  which  serves  as  a  stilt,  and  above  in 
a  ring  that  fits  the  upper  extremity  of  the  thigh,  and  supports 
the  weight  of  the  body.  The  brace  is  made  of  iron  wire  from 
three-sixteenths  to  three-eighths  of  an  inch  in  thickness.  The 
ring  is  of  an  irregular  ovoid  shape,  flattened  in  front,  expanded 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        41 5 

behind,  and  wider  on  the  inner  than  on  the  outer  side  (Fig.  254). 
This  ring  is  welded  to  the  uprights  at  a  lateral  and  anteropos- 
terior inclination.  The  lateral  inclination  forms  an  angle  with 
the  inner  bar  of  135  degrees  (Fig.  256),  the  anteroposterior 
inclination  forms  an  anterior  angle  of  145  degrees  (Fig.  255) 
with  the  same  upright,  which  is  set  upon  the  ring  at  a  point 
slightly  in  advance  of  its  fellow.  The  objects  of  the  shape  of 
the  ring  and  of  its  inclination  are  these  :  its  anterior  part  is  flat, 
because  the  surface  of  the  groin  is  flat ;  its  posterior  segment 
is  expanded  to  accommodate  the  thickness  of  the  buttock ;  the 


Fig.  256. 


Fig.  257. 


Showing  the  front  of  the  ring  of  the 
Thomas  knee-splint. 


Showing  the  hack  of  the  ring  of  the 
Thomas  knee-splint.    (Ridlon.) 


anteroposterior  inclination  allows  the  ring  to  rest  comfortably 
beneath  the  tuberosity  of  the  ischium.  The  lateral  inclination 
which  follows  the  line  of  Poupart's  ligament  is  made  necessary 
by  the  greater  length  of  the  outer  bar,  which,  in  order  to  assure 
better  support  and  less  pressure,  rises  above  the  level  of  the  tro- 
chanter major. 

The  ring  is  made  somewhat  larger  than  the  thigh  to  allow  for 
padding  with  felt.  This  should  be  thicker  on  the  inner  and 
posterior  surface,  where  the  weight  is  bonie,  tliaii  on  the  anterior 
and  outer  part.  The  padded  ring  is  then  smoothly  covered 
vvitli  basil  loatlier.     As  used  at  tlie  Hos])ital  for  Ruptured  and 


416 


ORTHOPEDIC  SURGERY. 


Fig.  258. 


Crippled,  the  brace  is  made  from  two  to  three  inches  longer  than 
the  leg,  to  serve  as  a  stilt  like  the  hip  splint.  To  the  foot-piece 
two  straps  are  attached  on  either  side  to  provide  for  traction  on 
the  limb  and  to  hold  the  brace  securely  in  its  place.  A  band  of 
leather  is  drawn  between  the  bars  at  the  upper  third  and  another 

at  the  lower  third  of  the  brace  to 
serve  as  supports  for  the  thigh  and 
calf.  Adhesive  plasters,  reaching 
from  the  knee  to  the  ankle,  pro- 
vided with  buckles  above  the  mal- 
leoli, having  been  applied,  the  ring 
is  pushed  firmly  against  the  per- 
ineum and  is  held  in  position  by 
buckling  the  straps  to  the  traction 
plasters  with  as  much  tension  as 
the  comfort  of  the  patient  will  per- 
mit. The  thigh  and  leg  supports 
should  fit  the  parts  perfectly ;  the 
knee  is  then  fixed  in  its  place  by 
a  bandage  drawn  tightly  about  it 
and  the  lateral  bars.  Ankle  and 
heel  straps  complete  the  adjust- 
ment (Fig.  258). 

In  cases  in  which  the  joint  is  sen- 
sitive and  in  which  there  is  a  ten- 
dency to  deformity  the  entire  limb 
is  in  addition  enclosed  in  a  light 
plaster  bandage,  so-called  "  skin 
fitting,"  applied  directly  upon  a 
flannel  bandage. 

If  the  brace  is  attached  by  means 
of  the  adhesive   plaster  straps,   a 
The  Thomas  knee-brace.  Certain  amount  of    tractiou  is  as- 

sured, together  with  additional 
accuracy  of  adjustment;  and  by  the  traction  and  by  the  direct 
pressure  on  the  knee  the  slighter  degrees  of  deformity  may  be 
reduced  without  discomfort.  In  acute  cases  preliminary  rest  in 
bed  is  advisable,  and  crutches  may  be  employed  in  the  early  stages 
of  ambulatory  treatment.  But  during  the  greater  part  of  the 
disease  the  splint  serves  as  a  perineal  crutch,  and  by  the  use  of 
slight  corrective  force  when  the  plaster  bandages  are  applied,  or 
by  traction  at  times  toward  one  or  the  other  upright,  lateral  dis- 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        417 

tortion  of  the  limb  may  be  corrected  during  the  course  of  treat- 
ment. This  brace  may  be  used  in  the  treatment  of  very  young 
children  if  it  is  carefully  fitted  and  if  the  parts  are  kept  clean  and 
dry,  and  it  is  an  effective  brace  for  all  ages,  and  for  all  conditions 
of  disease. 

The  Caliper  Brace.  The  traction  may  be  discarded  and  the 
brace  may  be  held  in  position  by  a  shoulder  band,  or  it  may  be 
used  as  a  so-called  caliper  splint.  In  this  form  it  was  almost 
exclusively  employed  by  Mr.  Thomas  in  his  later  practice  and  at 
the  present  time  by  Ridlon,^  the  long  brace  being  used  simply  for 
a  bed  splint.  As  a  caliper  brace  the  two  bars  are  cut  off,  turned 
directly  inward  at  a  right  angle,  and  are  inserted  into  a  steel 
tube,  which  is  passed  through  the  heel  of  the  shoe.  The  bars  are 
made  slightly  longer  than  the  limb,  so  that  the  patient's  heel  is 
lifted  nearly  an  inch  from  the  inside  of  the  shoe  when  walking  ; 
thus,  the  jar  of  impact  with  the  ground  is  prevented.  The  brace 
is  fixed  in  position  by  a  leather  band  beneath  the  knee  and  another 
beneath  the  calf,  and  the  limb  is  held  extended  by  pressure  pads 
applied  to  the  thigh  and  leg,  as  illustrated  (Fig.  259).  Ridlon 
uses  the  brace  to  reduce  deformity  by  direct  pressure  backward  on 
the  knee  by  means  of  bandages,  opiates  being  given  to  relieve 
pain. 

Other  braces  may  be  employed,  for  example,  the  traction  hip 
splint,  but  as  the  Thomas  brace  answers  every  requirement  it  seems 
unnecessary  to  describe  others  in  this  connection. 

Accessory  Treatment,  The  accessories  to  protective  treatment, 
which,  of  course,  includes  the  proper  attention  of  the  general  con- 
dition of  the  patient,  are  local  applications,  injections,  and  venous 
stasis.  They  are  classed  as  accessories  because  none  of  them  is 
essential  to  successful  treatment. 

The  local  application  of  cautery,  applied  at  intervals  of  a  week 
or  less,  may  add  to  the  comfort  of  the  patient  and  stimulate  the 
reparative  processes.  The  X-ray  appears  to  act  in  a  somewhat 
similar  manner ;  it  relieves  pain,  and  in  most  instances  the  infil- 
tration of  the  tissues  becomes  less  marked. 

Ichthyol  ointment  of  a  strength  of  about  40  per  cent,  certainly 
relieves  pain  and  local  congestion  in  certain  instances.  Firm 
compression  by  means  of  a  flannel  bandage  and  by  the  adhesive 
plaster  strapping  is  of  value,  especially  in  the  infiltrating,  "  boggy  " 
type  of  disease. 

1  Transactions  American  Ortliopedic  Association,  vol.  vi. 
27 


418 


ORTHOPEDIC  SURGERY. 


Fig.  259. 


The  knee  is  the  joint  into  which  injections  of  iodoform  emulsion 
may  be  made  most  easily.  Such  injections  are  more  likely  to  be 
of  service  in  the  synovial  than  in  the  osteal 
type  of  disease.  About  10  c.c.  of  a  10  per 
cent,  emulsion  of  iodoform  in  sweet  oil  may 
be  injected  through  a  trocar  into  the  dis- 
tended capsule  at  intervals  of  several  weeks. 
It  is  then  distributed  by  gentle  massage.  It 
may  aid  the  reparative  processes  by  an  irri- 
tative stimulation,  but  it  apparently  exerts 
no  very  direct  influence  on  the  tuberculous 
process. 

Bier's  treatment  by  passive  congestion 
may  be  easily  applied  to  the  joint.  The 
limb  up  to  the  joint  is  firmly  bandaged  by 
a  flannel  bandage.  A  rubber  band  is  then 
applied  immediately  above  the  joint  with 
sufiicient  tension  to  retard  the  return  of  the 
venous  blood.  The  joint  then  becomes 
swollen  and  congested.  The  congestion  is 
at  first  used  for  an  hour  or  more  at  a  time 
once  or  twice  daily.  Later  it  may  be  ap- 
plied continuously.  Passive  congestion  ap- 
parently increases  the  stability  of  the  granu- 
lation tissue  and  its  further  transformation 
to  fibrous  tissue.  The  method  should  not 
be  employed  during  the  acute  phases  of  the 
disease.      (See  page  259.) 

Treatment  during  Convalescence.  During 
the  active  stage  of  the  disease  the  brace  must 
be  worn  day  and  night;  during  the  stage  of 
recovery  it  may  be  removed  at  night  to  allow 
for  motion  at  the  knee,  and  later  a  form  of 
walking  brace  (Fig.  176)  that  will  allow  a 
limited  motion  at  the  knee  may  be  of  service  ; 
but  this  is  not  an  essential  in  treatment.  If 
slight  knock-knee  remains  after  recovery, 
it  may  be  overcome  by  the  use  of  a  Thomas 
knock-knee  brace,  which  will  also  serve  as  a 
protection  to  the  weak  joint. 
The  indications  of  cure  have  been  discussed  under  hip  disease. 
In  brief,  when  sufficient  time  has  elapsed  to  permit  of  natural 


The  caliper  splint.  E,  the 
ring  around  the  upper  part 
of  the  thigh.  A,  pad  for 
backward  pressure.  B, 
bandage.  C,  bandage.  F, 
leather  sling  for  support  at 
the  bacli  of  the  limb.  D,  a 
strip  of  bandage  fastening 
together  the  pressure  pads 
to  prevent  slipping  and  con- 
sequent loss  of  pressure. 
(Ridlon  and  Jones.) 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        419 

cure  ;  when  there  have  been  no  symptoms  of  active  disease  for 
months  ;  when  muscular  spasm  has  disappeared,  one  may  tenta- 
tively remove  the  brace  in  the  manner  described.  But  any 
symptom  of  disease,  and  particularly  increasing  limitation  of  the 
range  of  motion,  or  a  tendency  toward  deformity,  indicates  the 
necessity  for  continued  protection. 

If  anchylosis  is  present  supervision  and  occasional  treatment 
will  be  required  during  the  period  of  growth  in  order  to  prevent 
deformity. 

Extra-articular  Disease  and  Operative  Intervention.  In  certain 
cases,  especially  in  young  children,  the  disease  about  the  epi- 
physeal cartilage  of  the  femur  or  of  the  tibia  may  find  its  way  to 
the  exterior  of  the  bone  before  it  invades  the  joint.  This  fortu- 
nate course  is  indicated  by  local  sensitiveness  and  swelling  over 
one  of  the  condyles  of  the  femur  or  about  the  head  of  the  tibia. 
In  such  instances  the  thorough  removal  of  the  disease  is  indi- 
cated, or  if  a  Roentgen  picture  shows  that  the  disease  is  accessible, 
even  though  it  is  not  immediately  below  the  surface,  an  explora- 
tory operation  may  be  advisable.  An  incision  is  made,  usually 
over  the  internal  condyle  of  the  femur.  The  periosteum  is  raised 
and  a  portion  of  the  cortex  is  removed  in  order  to  expose  the 
spongy  bone  on  either  side  of  the  epiphyseal  cartilage. 

In  many  instances  an  area  of  softening  will  be  found.  This 
must  be  thoroughly  removed.  The  cavity  may  be  treated  with 
pure  carbolic  acid  or  the  cautery,  or  filled  with  iodoform  emulsion 
or  paraffin,  and  the  wound  is  then  closed.  In  favorable  cases 
prompt  operative  intervention  may  cut  short  the  course  of  the 
disease. 

Abscess.  Abscess  is  present  as  a  complication  in  about  one- 
third  of  the  cases  that  have  received  efficient  protection,  and  in  a 
larger  percentage  of  those  in  which  treatment  has  been  neglected. 

It  was  present  in  51  per  cent,  of  Koenig's  cases^  and  in  47  per 
cent,  of  three  hundred  final  results  reported  by  Gibney.^  At  the 
knee,  as  at  other  joints,  the  infected  abscess  is  the  most  dangerous 
complication  of  the  disease,  as  is  illustrated  by  Koenig's  statistics  : 

Death-rate  in  cases  without  abscess 25  per  cent. 

"  "  with  abscess 46       " 

Although  in  many  instances  abscess  indicates  an  extensive  and 
destructive  disease  of  the  bone,  yet  the  exhausting  suppuration 
that  is  an  indirect  cause  of  death  is  suppuration  from  infected 

'  Loo.  cit.  2  American  Journal  of  the  Medical  Sciences,  October,  1893. 


420  ORTHOPEDIC  S  UB  GER  Y. 

areas  in  the  thigh  and  leg,  which  may  have  little  direct  relation 
to  the  extent  of  the  original  disease.  It  should  be  the  aim  in 
treatment  to  prevent  this  burrowing  of  fluid  after  the  capsule  has 
been  perforated,  and  to  prevent  overdistention  of  the  capsule  even 
in  order  to  lessen  the  macerating  effect  of  the  tuberculous  fluid 
upon  the  cartilages.  When  the  fluid  within  the  joint  is  of  con- 
siderable amount,  and  when  it  is  increasing  in  quantity,  it  may 
be  removed  by  aspiration,  or  a  better  procedure  is  to  incise  the 
capsule.  This  will  allow  a  thorough  removal  of  its  fluid  and 
solid  contents,  after  which  the  opening  may  be  closed  with 
sutures. 

Tuberculous  abscess  w'hich  has  perforated  the  capsule  may  be 
treated  in  the  same  manner,  or  it  may  be  drained  subsequently, 
according  to  the  indications.  Unless  the  abscess  is  infected 
careful  bandaging  of  the  thigh  and  leg  should  prevent  burrowing. 

Synovial  Tuberculosis.  In  the  forms  of  synovial  tuberculosis 
that  resemble  chronic  synovitis  the  fluid,  if  the  quantity  is  large, 
may  be  evacuated  by  an  incision  in  the  capsule  which  will  allow 
for  exploration  and  for  removal  of  the  fibrinous  masses  that  are 
often  present.  Afterward  the  interior  of  the  joint  may  be  treated 
with  an  application  of  a  strong  solution  of  chloride  of  zinc  or  pure 
carbolic  acid.  This  sets  up  an  active  reaction  w^hich  causes  adhe- 
sions within  the  capsule,  and  exerts  a  favorable  influence  on  the 
course  of  the  disease.  A  protective  brace  should  be  worn  to 
guard  the  joint  from  sudden  twists  and  strains  and  to  limit  the 
range  of  motion  within  the  painless  arc.  The  adhesive  plaster 
strapping  may  be  employed  in  cases  of  this  type  with  great  advan- 
tage. Such  a  brace  is  shown  in  Fig.  176.  The  injection  of 
iodoform  emulsion  should  be  of  particular  advantage  in  the  treat- 
ment of  this  form  of  disease.  Theoretically,  its  use  should 
modify  the  infectious  quality  of  the  tuberculous  fluid  and  lessen 
the  danger  of  infection  Avith  pyogenic  germs,  and  on  this  ground, 
rather  than  because  it  actually  shortens  the  course  of  the  disease, 
it  may  be  recommended. 

Arthrectomy.  When,  as  in  exceptional  cases,  the  disease  is 
progressive  and  shows  no  tendency  toward  recovery,  and  particu- 
larly if  an  infected  abscess  communicating  with  the  joint  makes 
efficient  drainage  difficult,  the  operation  of  arthrectomy  may  be 
indicated. 

An  Esmarch  bandage  having  been  applied,  the  joint  is  thor- 
oughly exposed  by  a  curved  anterior  incision  passing  above  or 
below  or  through  the  patella,  and  all  the  diseased  tissue  is  re- 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        421 

moved ;  that  in  the  soft  parts  is  cut  away,  and  foci  in  the  bone 
are  excavated  with  the  chisel  and  scoop.  If  infection  be  present 
the  joint  may  be  packed  with  gauze,  the  leg  being  fixed  in  the 
position  of  flexion  ;  but  in  other  instances  the  wound  is  closed 
with  or  without  drainage  as  may  seem  advisable.  In  a  large 
proportion  of  cases  primary  healing  may  be  obtained.  By  the 
procedure  one  may  hope  to  cure  the  disease,  but  in  all  but  excep- 
tional cases  the  functional  result  will  be  anchylosis.  The  opera- 
tion has  the  advantage  over  excision  in  that  less  bone  is  removed, 
and  that  the  epiphyseal  cartilages,  in  part,  at  least,  remain ;  thus, 
the  immediate  as  well  as  the  ultimate  shortening  is  less  than  after 
excision. 

Results  of  Arthrectomy.  The  direct  death-rate  of  the 
operation  is  small.  In  150  cases  reported  by  Koenig  but  3  deaths 
were  attributable  to  the  operation  itself.  The  final  results  in  114 
of  these  cases,  in  which  the  operation  was  performed  in  childhood, 
were  as  follows  : 

Patients  cured  and  living 90 

Cured  of  the  local  disease,  but  not  living  at  the  time  of 

the  investigation 10 

Practically  cured,  insignificant  fistulse  remaining       .       .      2  '■ 

102  =  89.5  per  ct. 

Living,  not  cured 5 

Deaths  before  the  cure  of  the  local  disease  ....      7 

12  =  10.5  per  ct. 

Thus  in  89  per  cent,  of  the  cases  the  operation  was  successful 
as  far  as  the  cure  of  the  local  disease  was  concerned.  In''75  per 
cent,  of  the  successful  cases  immediate  cure  was  attained ;  in  ^5 
per  cent,  fistulse  persisted  for  a  longer  or  shorter  time.  In  10 
cases  some  motion  was  retained,  but  in  the  others  anchylosis  fol- 
lowed the  operation.  In  about  70  per  cent,  of  the  cases  the  lirdb 
was  practically  straight ;  in  30  per  cent,  it  was  distorted.  This 
shows  the  necessity  of  continued  supervision  and  in  many  in- 
stances of  protective  treatment  during  the  growing  period  in  all 
cases  in  which  anchylosis  is  present  from  whatever  cause. 

In  forty-eight  cases  in  which  the  operation  had  been  performed 
before  the  tenth  year,  and  in  which  the  limbs  were  straight,  the 
influence  of  the  operation  on  the  growth  was  investigated. 

Years  elapsed         Average  shortening 

Numher  of  cases.                                                  since  operation.  in  cm. 

6 2  1 

5 3  1.6 

4 4  1 

3 5  2 

19 G-7  2 

11 8-13  2.5 


422 


OB THOPEDIC  SURGEB  Y. 


These  measurements  indicate  that  the  shortening  is  not  likely  to 
be  very  great  as  a  result  of  the  operation,  certainly  very  much  less 
than  after  complete  or  even  partial  excision  performed  at  the 
same  age. 

Excision.  Excision  of  the  joint  in  childhood  has  been  practi- 
cally abandoned,  because  of  the  great  shortening  that  follows 
complete  removal  of  the  epiphyses,  and  because  so-called  partial 
excision — that  is,  the  removal  of  the  thin  sections  of  bone  from 

the  surfaces  of  the  femur  and 
tibia,  leaving  the  cartilages 
— is  usually  an  unnecessary 
operation,  in  the  sense  that 
disease  that  might  be  cured 
by  this  procedure  might  have 
been  cured  by  conservative 
methods. 

Early  excision  in  adult 
cases  is  often  indicated  be- 
cause it  will  assure  a  cure  of 
the  disease  in  a  short  time, 
whereas  mechanical  treat- 
ment will  require  years  of 
disability  with  no  certain 
prospect  of  absolute  cure  at 
the  end  of  the  period.  If, 
therefore,  the  disease  has  pro- 
gressed sufficiently  to  indicate 
that  the  natural  cure  would 
result  in  anchylosis,  or  if 
the  time  required  for  natural 
cure  is  of  importance  to  the 
patient,  early  excision  may 
be  advised  in  the  case  of  the  adult  or  adolescent  whose  gro^vth 
is  nearly  completed. 

The  operation  is  performed  under  the  Esmarch  bandage,  and 
the  joint  is  exposed  by  the  anterior  incision,  as  in  the  operation  of 
arthrectomy.  All  the  diseased  tissues  are  cut  away  and  sections 
of  the  bones,  parallel  to  the  articular  surfaces,  are  removed, 
sufficient  in  depth  to  include  all  the  diseased  area.  If  the  sec- 
tions are  so  made  as  to  allow  the  bones  to  be  brought  into  close 
apposition,  sutures  through  the  periosteum  will  hold  them  in 
position,   without  nuls   or    wiring.       The   vessels  having  been 


Deformity  and  shortening  resulting  from  ex- 
cision of  the  knee  in  childhood. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.       423 

ligated,  the  wound  may  be  closed  with  or  without  drainage,  as 
may  be  indicated  by  the  character  of  the  disease,  a  plaster-of- 
Paris  dressing  is  applied,  and  the  limb  is  elevated.  Mechanical 
support  is  of  service  in  the  after-treatment  in  lessening  the 
discomfort  and  hastening  the  cure. 

Results  of  Excision.  In  Koenig's  statistics  of  300  ex- 
cisions, 6  deaths  were  due  directly  to  the  operation,  and  23  others 
occurred  during  the  course  of  the  after-treatment — a  total  of  29 
(9.6  per  cent.). 

In  23  instances  amputation  was  afterward  performed  because 
of  failure  of  the  operation.  The  good  results  are  classed  by 
Koenig  as  75  per  cent.,  the  bad  as  25  per  cent.  In  193  cases 
the  position  of  the  limb  in  after  years  was  investigated.  It  was 
straight  in  175,  distorted  in  18,  all  but  1  of  this  latter  group 
being  in  children. 

Amputation.  This  operation  is  indicated  as  a  life-saving 
measure.  When  the  disease  is  so  extensive  as  to  require  com- 
plete removal  of  the  epiphyses  in  early  childhood,  amputation  is 
the  preferable  operation,  as  the  limb,  aside  from  requiring  con- 
stant protection  to  prevent  deformity,  will  be  so  short  as  to  be  of 
little  practical  use. 

Operations  for  the  Relief  of  Final  Deformity.  In  the  majority 
of  the  cases  deformity  can  be  rectified  by  one  of  the  methods 
already  described.  If,  however,  there  is  bony  anchylosis  in  an 
attitude  of  marked  flexion  the  limb  may  be  straightened  by  the 
removal  of  a  sufficient  wedge  of  bone  from  the  joint.  The  de- 
formity may  be  remedied  almost  equally  well  by  linear  osteotomy 
of  the  femur  just  above  the  joint,  and  this  operation  is  to  be 
preferred  in  young  subjects,  as  no  bone  is  removed. 

Genu  valgum  may  be  corrected  by  a  similar  operation.  (See 
Osteotomy  for  Knock-knee.) 

Prognosis.  The  most  important  statistical  evidence  on  the 
course  and  the  outcome  of  tuberculous  disease  of  the  knee-joint 
in  childhood  has  been  presented  by  Gibney.  The  statistics  com- 
pleted in  1892  were  the  result  of  an  investigation  of  499  cases 
treated  during  a  period  of  twenty  years,  1868-1887.  In  but 
300  of  these  could  definite  information  be  obtained.^ 

Eighty-seven  per  cent,  of  the  cases  were  in  children,  and  51 
per  cent,  of  the  patients  were  less  than  five  years  of  age  at  the 
inception  of  the  disease. 

'  American  Journal  of  the  Medical  Sciences,  October,  1893. 


424 


ORTHOPEDIC  SURGERY. 


The  cases  were  divided  into  three  classes,  according  to  the 
treatment  that  had  been  followed  : 

1.  The  expectant  treatment.  In  this  class  no  apparatus  was 
employed,  or,  if  employed,  it  was  inefficiently  used. 

2.  The  fixation  treatment.  In  this  class  the  joint  was  more 
or  less  efficiently  splinted,  but  not  protected  from  impact  with 
the  ground. 

3.  The  protective  treatment.  In  this  class  the  joint  was  both 
splinted  and  protected  from  jar,  and  the  mechanical  treatment 
was  efficient. 

The  results  were  classified  as  follows : 


Total. 

Excisions. 

Amputations. 

Deaths. 

Under 
treatment. 

Cured. 

Expectant  . 
Fixation     . 
Protection  . 

71 
190 
39 

5 
9 
0 

3 

1 
0 

3 

35 

2 

9 
31 
11 

51 

114 

26 

300 

14 

4 

40 

51 

191 

Mortality.  The  total  deaths  in  the  300  cases  were  40  (13.3 
per  cent.)  ;  26  of  these  were  from  causes  directly  or  indirectly 
connected  with  the  disease  (8.6  per  cent.),  viz. : 

Operative  shock .1 

Prolonged  suppuration 16 

Tuberculous  meningitis 6 

Phthisis 3 

26 
Intercurrent  diseases 14 

40 

Function.  The  functional  results  as  regards  motion  in  the 
cases  in  which  conservative  treatment  was  continued  to  the  end, 
including  the  cases  still  under  observation,  242  of  300,  were  as 
follows  : 


Total. 

Motion  retained. 

Anchylosed. 

Expectant 

Fixation 

Protection 

60 

145 

37 

44  or    7  per  ct. 
113  "  77 
34  "  95 

16 

32 

3 

242 

191  or  79  per  ct. 

51 

Of  the  191   patients  who  retained   a  movable  joint,   74  had 
had  abscesses,  3  or  more  cicatrices  being  present  in  39. 

As  to  the  range  of  motion,  in  74  it  was  from  45  degrees  to 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT.        425 

normal  and  in  41  more  than  90  degrees;  thus  30  per  cent,  of  the 
patients  retained  a  fair  range  of  motion. 

Deformity.  In  51  cases  anchylosis  was  present;  in  16  of  these 
the  limb  was  practically  straight,  in  35  it  was  flexed  more  than 
30  degrees  (69  per  cent.). 

These  statistics  again  illustrate  the  great  tendency  toward 
deformity,  when  during  the  growing  period  there  is  anchylosis  at 
the  knee  from  whatever  cause. 

In  the  191  cases  in  which  motion  was  retained  the  limb  was 
practically  straight  in  125  (65  per  cent.).  In  49  others  the 
flexion  was  less  than  25  degrees,  and  in  but  16  could  the 
deformity  be  classed  as  bad  (8  per  cent.). 

In  10  cases  only  did  relapse  occur  after  apparent  cure. 

In  but  16  of  the  449  cases  was  there  involvement  of  other 
joints  while  the  patients  were  under  observation  (3.2  per  cent.). 
In  8  of  these  the  spine  was  iuvolved,  in  2  the  hip,  and  in  6 
other  joints. 

The  influence  of  age  upon  the  death-rate  and  the  ultimate 
causes  of  death  are  illustrated  by  Koenig's  statistics,  the  death- 
rate  being  much  higher,  at  least  in  the  cases  in  early  childhood, 
than  in  this  country. 

According  to  Koenig's  statistics,  the  death-rate,  direct  and 
indirect,  from  disease  of  the  knee-joint,  was  as  follows  : 

323  children  (  1  to  15  years  of  age),       deaths  .  .  65  =  20  per  cent. 

225  patients  (16  "  30      "  "    ),  "  .  .  61  =  24 

68        "         (31  "  40      "  "    ),  "  .  .  30  =  44 

74       "         more  than  40  years  of  age      "  .  .  45  =  60       " 

Causes  of  Death. 

Deaths  from  causes  not  connected  with  the  disease       .    14  =  2  per  cent. 

"       following  operations 18  =  2.5      " 

"       caused  by  tuberculosis,  141  =  22.5  per  cent,  of  all  eases  and 
80  per  cent,  of  all  the  deaths. 

Tuberculosis  of  the  knee 1 

"  "       lungs 94 

General  tuberculosis 30 

Tuberculous  meningitis .7 

Acute  miliary  tuberculosis 3 

Tuberculosis  of  other  parts 6 

141 

It  may  be  noted  that  16  of  the  40  deaths  in  Gibney's  cases 
were  due  to  prolonged  suppuration,  and  that  of  51  cases  still 
under  observation  26  had  been  treated  for  ten  years  or  longer, 
and  were  still  uncured.  This  indicates  that  in  a  larger  propor- 
tion of  the  cases  conservative  methods  should  have  been  supple- 


426  ORTHOPEDIC  SURGERY. 

mented  by  more  radical  treatment.  Still,  taken  as  a  whole,  the 
results,  although  the  mechanical  treatment  was,  in  many  instances, 
far  from  efficient,  are  much  better  than  any  others  that  have  been 
presented. 

General  Conclusions.  On  this  evidence  the  folio  wine: 'con- 
elusions  seem  to  be  justified.  The  death-rate  in  childhood  from 
all  causes  should  be  less  than  10  per  cent.  The  duration  of 
treatment  is  from  two  to  five  years.  Recovery  with  a  useful 
range  of  motion,  when  the  diagnosis  has  been  made  at  an  early 
stage  and  when  efficient  mechanical  treatment  has  been  employed, 
may  be  predicted  in  50  per  cent,  of  the  cases. 

Deformity  can  always  be  prevented  by  treatment  and  by  super- 
vision. Under  favorable  conditions  radical  operations  are  not 
often  indicated,  but  when  indicated  they  should  not  be  delayed 
too  long.  Amputation  of  the  limb  should  prevent  death  from 
prolonged  suppuration.  In  a  certain  proportion  of  cases  the 
disease  may  be  cut  short  by  early  exploratory  operations,  for  the 
removal  of  foci  of  disease  in  the  bone  before  the  joint  has  become 
involved. 

Although  the  benefits  of  protective  treatment  are  as  evident  in 
disease  of  the  adult  as  in  childhood,  yet  early  operation  is  often 
indicated  in  this  class,  because  of  the  necessity  for  shortening  the 
period  of  disability,  and  because  excision  assures  a  straight  and 
useful  limb. 


CHAPTER  X. 

NON-TUBERCULOUS    AFFECTIONS    AND     DEFORMITIES     OF 
THE  KNEE-JOINT. 

Strains  and  Injuries  of  the  Knee  in  Childhood. 

Injuey  of  the  knee  in  childhood  may  cause  local  discomfort 
and  persistent  flexion  of  the  leg,  even  when  but  little  synovial 
effusion  is  present.  In  this  class  of  cases  the  application  of  a 
plaster  bandage,  under  sufficient  traction  to  overcome  the  deform- 
ity, is  of  service  in  placing  the  part  at  rest  and  preventing  further 
injury.  The  importance  of  treating  promptly  slight  injuries  of 
the  joints  in  childhood,  especially  in  the  class  of  patients  predis- 
posed to  tuberculous  infection,  has  been  mentioned  already  in  the 
consideration  of  hip  disease. 

Muscular  "  cramp"  a  form  of  tetanic  contraction,  induced 
possibly  by  injury,  which  fixes  the  limb  in  a  flexed  or  extended 
position,  is  sometimes  seen  in  children  of  a  susceptible  or  nervous 
temperament.     The  treatment  is  similar  to  that  of  strains. 

Synovitis. 

Acute  traumatic  synovitis  is  properly  treated,  immediately  after 
the  injury,  by  splints,  by  elevation  of  the  limb,  by  the  application 
of  ice-bags  and  the  like  ;  but  after  the  acute  symptoms  have  sub- 
sided the  absorption  of  the  effused  fluid  is  aided  by  functional 
use  of  the  limb,  if  the  joint  is  properly  protected.  One  of  the 
most  efficient  methods  of  treatment  is  that  by  means  of  the  adhe- 
sive plaster  strapping  advocated  by  Cottrell  and  Gibney.  The 
entire  surface  of  the  knee,  except  a  narrow  space  in  the  popliteal 
region,  is  firmly  strapped  with  overlapping  layers  of  adhesive 
plaster,  extending  from  the  upper  third  of  the  leg  to  the  middle 
third  of  the  thigh  ;  and  over  this  a  flannel  bandage  is  applied  ; 
or  if  the  leg  is  swollen,  the  entire  limb  should  be  firmly  bandaged 
with  elastic  stockinette  bandage,  from  the  toes  to  the  upper  third 
of  the  thigh  in  addition  (Fig.  267).  The  adhesive  plaster  serves 
as  a  support  which  allows  a  certain  degree  of  motion,  sufficient  to 
stimulate  the  circulation,  and  thus  to  hasten  the  restoration  of 


428  ORTHOPEDIC  SUBGEBY. 

the  normal  condition.  If  greater  compression  is  desired,  the 
entire  joint  may  be  covered  with  the  adhesive  plaster  as  suggested 
by  Hoffmann/  A  pad  o£  cotton  is  placed  in  the  popliteal  space, 
a  close-fitting  stocking  leg  is  drawn  over  the  knee,  and  about 
this  circular  bands  of  plaster  are  drawn  as  tightly  as  the  comfort 
of  the  patient  will  permit.  The  adhesive  plaster  strapping  is 
renewed  from  time  to  time,  as  the  swelling  diminishes,  and  its 
use  is  continued  until  the  symptoms  have  entirely  disappeared. 

Chronic  synovitis  may  be  treated  in  a  similar  manner,  although 
if  the  effusion  is  persistent  the  fluid  may  be  removed  by  aspira- 
tion. If  the  ligaments  are  lax,  a  supporting  brace  may  be 
required  for  a  time  (Fig.  176).  Massage  and  exercises  and  static 
electricity  are  of  service  in  the  stage  of  recovery  to  restore  the 
strength  and  activity  of  the  supporting  muscles. 

Infectious  Arthritis. 

Suppurative  arthritis  of  this  as  of  other  joints  should  be 
treated  by  free  incisions,  and  eflficient  drainage  should  be  assured. 
If  this  cannot  be  attained  by  ordinary  methods  the  capsule  should 
be  widely  opened  and  the  patella  divided  by  means  of  a  trans- 
verse anterior  incision.  The  interior  of  the  joint  may  then  be 
completely  exposed  by  flexing  the  leg  to  an  acute  angle,  as  sug- 
gested by  Mayo.  Mechanical  protection  is  usually  required  after 
the  immediate  symptoms  are  relieved.  The  subject  is  considered 
more  at  length  elsewhere.     (See  Chapter  VI.) 

Osteoarthritis. 

In  this  disease  several  joints  are  usually  involved,  but  occasion- 
ally the  affection  may  be  confined  to  the  knee.  The  early  symp- 
toms are  stiffness,  discomfort,  and  pain  more  noticeable  in  damp 
weather,  and  often  creaking  sensations  in  the  joint  are  appreciable 
to  the  patient.  At  intervals  the  symptoms  may  be  more  acute 
and  the  joint  becomes  hot  and  swollen ;  as  a  rule,  however,  they 
are  subacute  in  character.  The  progress  of  the  affection  is  slow, 
the  joint  becomes  somewhat  enlarged  and  irregular  in  outline,  the 
range  of  motion  becomes  more  restricted,  and  flexion  of  the  limb 
after  a  time  persists.     (See  Rheumatoid  Arthritis,  page  274.) 

Treatment.  The  general  and  constitutional  treatment  does 
not  require  especial  consideration   here.     Locally  massage  and 

1  New  York  Medical  Journal,  January  27, 1900. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT.     429 

the  hot-air  bath  may  add  to  the  comfort  of  the  patient  and  in- 
crease the  mobility  of  the  joint,  in  the  early  stage  of  the  affection 
at  least.  Static  electricity  has  been  employed  with  advantage  in 
certain  cases.  The  application  of  the  cautery  and  stimulating 
liniments  are  useful  in  relieving  pain,  and  the  support  of  a  flannel 
bandage  adds  much  to  the  comfort  of  the  patient.  In  many 
instances  a  brace  (Fig.  176)  may  be  employed  with  advantage  to 
lessen  the  strain  upon  the  part.  Operative  removal  of  the  hyper- 
trophied  synovial  membrane,  loose  bodies  or  irregular  projections 
of  bone  that  may  interfere  directly  with  movement,  is  sometimes 
of  service.     Excision  is  a  final  remedy  in  extreme  cases. 

Prepatellar  Bursitis. 

Synonym.     Housemaid's  knee. 

A  chronic  enlargement  of  the  bursa  lying  over  the  patella  and 
its  ligament  is  common  among  those  who  have  to  kneel  much 
of  the  time ;  hence  the  popular  name.  Occasionally  cases  of  acute 
bursitis,  in  which  there  is  considerable  effusion  into  the  sac,  are 
seen,  and  these  are  sometimes  mistaken  for  synovitis  of  the  knee. 

Treatment.  In  acute  cases  strapping  the  front  of  the  knee 
with  strips  of  adhesive  plaster  which  will  limit  motion  and  pro- 
vide compression  is  an  effective  treatment.  If  the  eff'usion  is 
considerable  it  may  be  relieved  by  aspiration.  In  chronic  cases 
cure  can  be  attained  only  by  the  removal  of  the  thickened  sac. 

Pretibial  Bursitis. 

Beneath  the  ligamentum  patellae,  occupying  the  space  between 
the  tendon  and  the  periosteum  of  the  tibia,  is  the  deep  pretibial 
bursa.  It  is,  according  to  the  investigations  of  Lovett,^  as  wide 
or  somewhat  wider  than  the  tendon  ;  its  upper  border  is  on  a 
level  with  the  joint,  its  lower  border  reaches  to  the  tubercle  of 
the  tibia,  and,  being  slightly  longer  on  the  outer  than  on  the 
inner  border,  it  is  somewhat  triangular  in  shape.  It  does  not 
communicate  with  the  knee-joint. 

Enlargement  of  this  bursa  is,  as  a  rule,  the  result  of  injury, 
but,  as  bursitis  elsewhere,  it  may  be  a  complication  of  infectious 
diseases,  rheumatism  and  the  like. 

Symptoms.  The  symptoms  are  stiffness  at  the  knee  and  pain 
on   sudden   movement,  especially  when  strain  is  exerted  on  the 

I  Boston  City  Hospital  Reports,  8th  series,  1897. 


430  OR  THOPEDIC  SUBGEB  Y. 

tendon  by  complete  flexion  or  extension  of  the  leg  as  in  active 
use.  The  tubercle  of  the  tibia  seems  enlarged  and  is  sensitive 
to  pressure,  and  a  swelling  on  either  side  of  the  ligament  is 
usually  evident. 

Treatment.  The  affection,  if  at  all  acute,  may  be  treated  by 
relieving  the  strain  and  pressure  on  the  tendon,  by  fixation  of 
the  limb  for  a  time  in  a  plaster  bandage  or  other  form  of  splint- 
Later  the  adhesive  plaster  strapping  will  provide  sufficient  fixa- 
tion and  pressure.  The  absorption  of  the  fluid  may  be  hastened 
by  the  application  of  the  cautery.  If  the  swelling  is  persistent, 
the  fluid  may  be  removed  by  aspiration  or  incision  or  removal  of 
the  sac. 

Enlargement  of  the  Superficial  Pretibial  Bursa. 

A  small  bursa,  lying  upon  the  insertion  of  the  ligamentum 
patellae,  may  become  enlarged,  causing  an  apparent  hypertrophy 
of  the  tubercle  of  the  tibia.  It  may  be  treated  by  strapping  with 
adhesive  plaster,  and  the  prominent  tubercle  should  be  protected 
by  some  form  of  bunion  plaster. 

Injury  of  the  Tibial  Tubercle. 

Osgood^  has  called  attention  to  the  fact  that  symptoms  resem- 
bling those  described  may  be  caused  by  partial  separation  of  the 
tubercle  of  the  tibia.  The  treatment  is  primarily  rest  in  the 
extended  posture. 

Bursae  and  Cysts  in  the  Popliteal  Region. 

Simple  inflammation  of  the  bursa  lying  between  the  inner  head 
of  the  gastrocnemius  and  the  semimembranosus  muscle  may  cause 
a  fluctuating  swelling  on  the  inner  side  of  the  popliteal  region. 
It  may  be  treated  by  compression  or  by  incision  as  may  seem 
advisable.  Cysts  in  the  popliteal  region  usually  communicate 
with  the  knee-joint  and  are  complications  of  rheumatic  or  tuber- 
culous disease.  They  are  of  interest  principally  from  the  diag- 
nostic standpoint. 

Internal  Derangement  of  the  Knee-joint.     (Hey.) 

The  term  internal  derangement  signifies  sudden  interference 
with  the  function  of  the  joint  which  may  be  due  to  (a)  loose 

1  Boston  Medical  and  Surgical  Journal,  January  29, 1903. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT.     431 

bodies  iu  the  joint  ;  (6)  displacement  or  fracture  of  a  semilunar 
cartilage  ;  (c)  other  injury.^ 

Loose  Bodies  in  the  Knee-joint.  Loose  bodies  in  the  knee- 
joint  may  be  composed  of  portions  of  fibrin,  fragments  of  synovial 
membrane,  or  bits  of  cartilage  or  bone,  and  the  like.  In  certain 
forms  of  synovial  tuberculosis  and  osteoarthritis  these  loose  bodies 
may  be  present  in  large  numbers,  but  from  the  therapeutical 
standpoint  the  important  cases  are  those  in  which  the  joint  is 
otherwise  normal.  In  this  class  the  foreign  body  is  sometimes 
detected  by  the  patient  as  a  smooth,  movable  object  on  one  or  the 
other  side  of  the  patella  ;  but  in  many  instances  the  first  sign  of 
its  presence  is  interference  with  the  function  of  the  joint.  After 
a  sudden  movement  or  when  the  knee  has  been  flexed,  as  in  the 
kneeling  position,  or  without  appreciable  cause,  severe  pain  in 
the  knee  is  felt  and  the  joint  may  be  fixed  in  the  position  of 
flexion.  By  massage,  manipulation,  or  spontaneously  the  foreign 
body  is  dislodged  from  between  the  surfaces  of  the  bones  and 
movement  becomes  free  and  painless,  but  discomfort  remains  for 
a  time  and  in  most  instances  synovial  effusion  follows.  These 
symptoms  recur  at  intervals,  and  the  disappearance  of  the  mov- 
able body  from  its  accustomed  place  at  such  times  demonstrates 
its  relation  to  the  disability. 

Displacement  of  a  Semilunar  Cartilage.  Displacement  of 
a  semilunar  cartilage  is  usually  of  traumatic  origin.  The  internal 
cartilage  is  usually  affected,  and  it  appears  to  be  caused  most  often 
by  an  outward  twist  of  the  tibia  upon  the  femur.  The  patient's 
limb  is  fixed  in  the  attitude  of  flexion,  and  in  certain  instances 
an  irregularity  may  be  detected  at  the  inner  and  upper  border 
of  the  tibia. 

To  replace  the  cartilage  the  leg  should  be  flexed,  then  suddenly 
extended  and  rotated  inward.  In  some  instances  an  anaesthetic 
may  be  required.  The  displacement  is  followed  by  discomfort 
and  synovial  effusion.  The  accident  having  once  occurred,  is 
likely  to  recur  ;  the  patient  recognizing  the  character  of  the 
movements  that  are  likely  to  cause  the  displacement,  also  the 
proper  manipulation  for  its  replacement. 

Injury,  In  other  instances  somewhat  similar  symptoms  may 
follow  injury  at  the  knee,  pinching  of  the  synovial  membrane, 
bruising  or  fracture  of  the  cartilage,  or  a  strain  of  one  of  the 
ligaments  within  the  joint,  being  assigned  as  causes.     In  cases  of 

1  W.  H.  Bennett.    Lancet,  January  6, 1900. 


432  OR THOPEDIG  8  UR  GER  Y. 

this  character,  in  which  symptoms  recur  from  time  to  time,  the 
joint  becomes  weak  and  insecure,  partly  because  of  the  repeated 
synovial  effusion  and  partly  because  of  the  muscular  relaxation. 

Treatment.  If  the  patient  is  seen  immediately  after  the  dis- 
placement or  injury  the  limb  should  be  fixed  in  a  plaster  bandage 
for  four  weeks  or  more  to  allow  for  reattachment  of  the  displaced 
part.  Afterward  it  may  be  protected  by  the  adhesive  plaster 
strapping,  and  when  the  effusion  has  been  absorbed  massage  and 
exercises  for  strengthening  the  muscles  should  be  employed. 

In  the  more  chronic  cases  in  which  the  ligaments  are  lax,  a 
brace  which  will  permit  anteroposterior  motion,  but  prevent 
lateral  mobility,  may  be  required.  The  Campbell  brace  (Fig. 
176)  used  by  Shaffer,  is  a  light  and  effective  support  that  inter- 
feres little,  if  at  all,  with  the  use  of  the  limb. 

If  the  diagnosis  of  displaced  or  fractured  cartilage  can  be 
verified,  and  if  it  is  the  cause  of  persistent  disability,  it  should 
be  removed.  And  the  same  may  be  said  of  isolated  foreign 
bodies,  which  are  known  to  be  the  cause  of  the  symptoms. 

Under  the  Esmarch  bandage  the  joint  is  opened  by  an  incision 
about  three  inches  in  length  on  the  anterolateral  aspect  of  the 
joint.  After  the  capsule  is  opened  the  leg  is  flexed  to  bring 
the  cartilage  into  view.  If  loose  it  is  then  separated  from  its 
attachments  with  a  tenotomy  knife  and  is  removed.  The  capsule 
is  then  united  with  a  fine  catgut,  the  wound  is  closed,  and  a 
plaster  bandage  is  applied.  At  the  end  of  a  week  or  more  the 
patient  may  walk  about.  At  the  end  of  a  month  the  adhesive 
plaster  strapping  may  replace  the  bandage.  Perfect  functional 
recovery  is  the  rule.  The  treatment  of  hypertrophied  and  con- 
gested synovial  membrane,  or  loose  bodies,  is  conducted  in  a 
similar  manner. 

Acquired   Genu  Recurvatum. 

Synonym.     Back  knee. 

Genu  recurvatum,  as  the  name  implies,  is  a  deformity  in  which 
the  knee  is  habitually  overextended. 

Etiology.  Acquired  genu  recurvatum  may  be  a  simple  local 
deformity,  or  it  may  be  secondary  to  weakness  or  distortion  of 
other  parts.  Local  or  primary  genu  recurvatum  may  be  an  effect 
of  rhachitis,  or  of  disease  or  injury  of  the  femur  or  tibia.  In 
this  form  the  femur  may  be  curved  sharply  forward  above  the 
joint,  or  the  upper  extremity  of  the  tibia  may  be  bent  backward 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT.     433 

at  the  epiphyseal  junction,  and  flexion  may  be  limited  by  the 
obliquity  of  the  articulating  surfaces. 

More  often  the  deformity  is  secondary.  It  may  be,  for 
example,  an  effect  of  equinus,  either  congenital  or  acquired,  in 
which  the  knee  is  strained  by  the  effort  of  the  patient  to  place 
the  heel  upon  the  ground.  It  may  be  caused  by  the  use  of  a 
brace  in  the  treatment  of  hip  disease,  if  the  knee-joint  is  not  prop- 
erly supported,  and  it  is  often  seen  also  as  a  result  of  disease  at 
this  joint,  for  which  no  apparatus  has  been  employed.  It  even 
appears  in  some  instances  on  the  sound  side,  apparently  as  a  form 
of  compensation  for  the  shorter  limb  (Fig.  189).  It  is  one  of  the 
comparatively  infrequent  complications  of  disease  at  the  knee- 
joint,  in  which  the  leg  has  been  supported  by  the  brace  in  an 
extended  or  overextended  position,  or  in  which  the  growth  at  the 
epiphyseal  cartilages  of  the  femur  or  tibia  has  been  irregular. 
In  rare  instances  it  is  the  direct  result  of  traumatism,  as  when 
the  limb  has  been  suddenly  forced  into  an  overextended  position, 
and  the  posterior  ligaments,  and  possibly  the  crucial  ligaments 
also,  have  been  ruptured  or  weakened.  It  is  most  often,  however, 
an  accompaniment  of  paralysis  of  the  posterior  thigh  muscles  or 
of  the  gastrocnemius  muscle,  or  both.  A  slight  degree  of  over- 
extension at  the  knees  is  not  uncommon  in  children  who  have 
the  so-called  loose  joints. 

In  many  cases  genu  recurvatum  is  combined  with  a  varying 
degree  of  knock -knee,  and  there  is  often  an  abnormal  mobility  at 
the  joint  that  allows  a  certain  amount  of  posterior  displacement 
of  the  tibia.  In  extreme  cases  of  this  class  there  may  be  well- 
marked  subluxation. 

Symptoms.  The  symptoms,  aside  from  the  deformity,  are 
weakness  and  insecurity  caused  by  the  hyperextension  when 
weight  is  borne.  If  the  deformity  is  extreme,  the  strain  upon 
the  weakened  parts  usually  causes  discomfort.  Flexion  is  ren- 
dered difficult  because  of  the  abnormal  relation  of  the  joint  sur- 
faces and  of  the  accommodative  changes  in  the  ligaments  and 
muscles,  so  that  in  extreme  cases  the  patient  swings  the  leg 
along  in  the  extended  or  overextended  position. 

Treatment.  If  the  recurvation  is  caused  by  deformity  of  the 
bones,  the  normal  relations  may  be  restored  by  osteotomy  of  the 
tibia  or  femur,  as  may  be  indicated.  Deformity  secondary  to  dis- 
tortions elsewhere  may  be  treated  by  remedying  the  primary  cause. 

Traumatic  genu  recurvatum  may  be  treated  by  fixation  in  the 
flexed  position  until  the  repair  is  complete,  afterward  by  massage 

28 


434  ORTHOPEDIC  SUBGEBY. 

and  support  if  necessary.  The  ordinary  form  of  overextended 
knee,  combined  with  lateral  mobility,  must  be  supported  by  a 
brace  which  permits  only  anteroposterior  motion  to  the  normal 
limit  or  slightly  less.  Whenever  possible  massage  and  exercises 
should  be  employed. 

Congenital  Genu  Recurvatum. 

Synonym.     Anterior  displacement  of  the  tibia. 

The  most  common  of  the  congenital  deformities  at  the  knee  is 
the  so-called  genu  recurvatum,  in  which  the  knee  is  bent  some- 
what backward  ;  or,  in  other  words,  the  leg  is  hyperextended  on 

Fig.  261. 


Congenital  genu  recurvatum.    (Hoifa.) 

the  thigh.  The  condition  is  often  spoken  of  as  an  anterior  dis- 
location, but  there  is  no  actual  displacement,  except  in  the  extreme 
cases  in  which  the  tibia  may  be  turned  directly  forward  on  the 
femur,  even  to  a  right  angle  or  less.  In  the  ordinary  cases  the 
range  of  extension  is  merely  exaggerated,  while  flexion  is  limited 
or  checked,  principally  by  adaptive  shortening  of  the  quadriceps 
extensor  muscle  (Fig.  261).  In  some  cases  there  may  be  changes 
in  the  direction  of  the  articulating  surfaces  in  adaptation  to  the 
deformity  of  the  femur  and  tibia.' 

The  appearance    in    well-marked    genu   recurvatum   is    very 
peculiar  ;  it  is  as  if  the  patient's  leg  were  reversed,  for  the  popliteal 

1  Delanglade.    Revue  d'Orthop^die,  May,  1903. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT.     435 

depression  has  become  a  prominence  and  the  range  of  overexten- 
sion seems  to  represent  normal  flexion.  In  such  cases  the  leg 
may  be  brought  to  the  straight  line,  but  greater  flexion  is  resisted 
by  the  retracted  tissues,  and  when  the  pressure  of  the  hand  is 
removed  the  leg  is  drawn  back  to  the  deformed  position  by  the 
contraction  of  the  quadriceps  extensor  muscle. 

Other  Deformities  and  Malformations,  Genu  recurvatum  is  not 
infrequently  accompanied  by  varus  or  valgus  deformity  at  the 
knee,  more  often  by  the  latter,  and  by  laxity  of  the  ligaments. 
In  many  instances  the  patella  is  absent  or  is  rudimentary,  and  not 
infrequently  the  deformity  is  accompanied  by  malformations  or 
defective  development  of  other  parts. 

Seventy-eight  cases  were  collected  by  Potel.^  In  37  instances 
the  deformity  was  limited  to  one  side ;  in  the  others  both  limbs 
were  affected.  In  50  cases  the  condition  of  the  patella  was  noted  ; 
in  26  of  these  it  was  absent  or  rudimentary.  Twenty  of  the  cases 
w-ere  accompanied  by  talipes. 

Etiology.  The  deformity  in  cases  of  simple  recurvatum  may 
be  explained  by  an  abnormal  and  fixed  position  in  utero,  and  in 
cases  seen  soon  after  birth  the  mechanism  is  clearly  shown  by  the 
habitual  attitude.  The  thighs  are  sharply  flexed  on  the  body ; 
the  dorsal  surfaces  of  the  hyperextended  knees  are  in  relation 
to  the  abdomen,  while  the  feet  may  be  brought  into  contact  with 
the  face  or  trunk,  according  to  the  degree  of  deformity.  The 
retarded  development  of  the  quadriceps  extensor  muscle  explains 
the  rudimentary  patella  which  is  often  an  accompaniment  of  the 
deformity. 

Treatment.  The  treatment  of  the  hyperextended  knee  is  very 
simple.  It  consists  in  massage  of  the  atrophied  and  contracted 
muscles,  combined  with  more  or  less  forcible  manipulation  in  the 
direction  of  flexion.  If,  as  is  often  the  case,  the  leg  seems  to  be 
drawn  forward  by  spasmodic  muscular  action,  the  methodical 
massage  should  be  combined  with  the  use  of  a  simple  posterior 
splint. 

In  the  more  extreme  cases  manual  force  may  be  applied  under 
ansesthesia,  and  the  deformity  may  be  overcome  at  one  or  several 
sittings,  according  to  the  resistance  of  the  contracted  parts.  The 
leg  is  then  fixed  in  a  flexed  position  until  the  tendency  to  recur- 
rence has  been  overcome.  When  the  child  begins  to  walk  a  light 
lateral  brace  may  be  necessary  to  insure  perfect  functional  use  of 

'  ICtude  sur  les  Malformations  Cong6nitale  du  Genou.    Lille,  1897,  Imp.  L.  Danel. 


436  ORTHOPEDIC  S UB GER  Y. 

the  joint,  as  in  many  instances  laxity  of  ligaments  and  muscular 
weakness  may  persist  for  a  long  time. 

Rudimentary  or  Absent  Patella. 

As  has  been  stated,  a  rudimentary  patella  is  a  frequent  com- 
plication of  genu  recurvatum  or  of  any  congenital  defect  or 
deformity  of  the  knee  or  limb  that  involves  imperfect  develop- 
ment of  the  quadriceps  extensor  muscle.  In  many  cases  of  this 
type  it  is  impossible  to  distinguish  the  patella  during  the  early 
months  of  infancy,  but  later  a  minute  patella  appears  that  slowly 
increases  to  an  approximately  normal  size. 

Absence  of  patella  under  the  same  conditions  is  less  frequent, 
although  Potel  collected  one  hundred  cases  from  literature. 

Treatment.  The  treatment  of  rudimentary  patella  is  included 
in  the  massage  and  stimulation  of  the  atrophied  or  rudimentary 
muscle  with  which  it  is  usually  associated,  and  the  support  that 
the  weak  or  deformed  knee  may  require. 

Congenital  Displacement  of  the  Patella. 

The  patella  may  be  displaced  upward  as  a  result  of  extreme 
genu  recurvatum,  and  in  rare  instances  it  may  be  displaced  inward 
or  downward,  but  far  more  often  the  displacement  is  outward. 
Fifty  cases  of  this  form  are  recorded,  in  most  of  which  it  was  a 
complication  of  congenital  genu  valgum. 

Slipping  Patella. 

This  term  is  applied  to  an  abnormal  laxity  of  the  supporting 
tissues  that  allows  occasional  displacement  of  the  patella  upon 
or  to  the  outer  side  of  the  external  condyle. 

Etiology.  This  disability  is  more  common  among  females 
than  males,  and  is  more  often  unilateral  than  bilateral.  The 
abnormal  mobility  may  be  an  inherited  peculiarity  ;  it  may  be 
due  to  weakness  of  the  quadriceps  extensor  muscle,  or  to  imper- 
fect development  of  the  patella  or  of  the  external  condyle ;  or  the 
original  displacement  may  have  been  due  to  injury.  In  many 
instances,  however,  the  predisposing  cause  is  genu  valgum,  as  a 
consequence  of  which  the  patella  is  carried  toward  the  external 
condyle. 

Weimuth^  has  collected  66  cases.     Of  these  32  were  of  con- 

1  Deutsche  Zeits.  f.  Chir,,  Bd.  Ixi.    Bade,  Zeits.  f.  Orthop.  Chir.,  1903,  Bd.  xi.  p.  3. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT.     437 

genital,  14  of  traumatic  (rupture  of  internal  ligaments),  and  20 
of  pathological  origin  (knock-knee). 

Symptoms.  If  the  slipping  of  the  patella  is  a  frequent  occur- 
rence it  causes  comparatively  little  pain,  but  when  the  parts  are 
less  relaxed  the  displacement  is  likely  to  be  followed  by  a  certain 
amount  of  effusion  into  the  joint  and  by  the  symptoms  of  a  sprain. 
It  is  usually  the  result  of  a  misstep  or  sudden  movement  when 
the  thigh  muscle  is  relaxed  or  of  extreme  flexion  of  the  leg.  As 
a  rule,  there  is  a  sense  of  insecurity  and  weakness  at  the  knee  in 
those  who  are  subject  to  the  accident. 

Treatment.  The  treatment  varies  according  to  the  condition 
of  the  parts  about  the  joint.  If  the  displacement  is  the  direct 
result  of  violence  the  leg  should  be  fixed  for  a  time  in  a  plaster 
bandage,  which  may  be  replaced  by  the  adhesive  plaster  strap- 
ping or  a  knee-cap.  Later  massage  and  muscle  training  should 
be  employed.  In  cases  in  which  the  slipping  has  become 
habitual  and  particularly  when  the  ligaments  of  the  joint  are 
much  relaxed,  a  light  brace  should  be  employed  to  prevent 
lateral  motion  and  to  limit  the  range  of  flexion  at  the  joint,  if 
this  predisposes  to  the  displacement  (Fig.  176). 

Operative  Treatment.  If  the  position  of  the  patella  that  pre- 
disposes to  the  further  displacement  is  a  consequence  of  genu 
valgum  the  rectification  of  the  deformity  will,  as  a  rule,  remedy 
the  secondary  disability.  If  the  displacement  appears  to  be 
caused  by  laxity  of  the  capsular  ligament,  as  well  as  by  the 
abnormal  position  of  the  patella,  an  operation  for  the  purpose  of 
limiting  the  mobility  and  restoring  the  proper  relation  of  parts 
may  be  conducted  in  the  following  manner  :  A  long,  curved 
incision  is  made  about  the  inner  side  of  the  knee,  the  lower 
extremity  of  which  crosses  the  ligamentum  patellae.  The  skin 
flap  having  been  reflected,  the  contracted  capsule  may  be  divided 
on  the  outer  side  without  disturbing  the  synovial  membrane.  The 
patella  is  then  forced  inward  and  the  redundant  tissue  on  the 
inner  side  is  folded  and  sutured,  or  a  section  of  the  capsule  may 
be  removed,  sufficient  in  size  to  hold  the  patella  in  its  proper 
position.  In  extreme  cases  the  tubercle  of  the  tibia,  with  the 
attached  tendon,  may  be  removed  and  reimplanted  on  the  inner 
aspect  of  the  tibia,  as  performed  by  Wolff  and  Walsham. 

The  limb  should  be  held  in  the  extended  position  for  a  time, 
and  it  should  afterward  be  supported  by  a  brace  or  knee-cap  for 
several  months.  Subsequently  massage  and  exercise  for  restoring 
the  tone  of  the  weakened  muscle  should  be  employed. 


438  ORTHOPEDIC  SURGERY. 

The  operation  for  the  dislocated  patella  has  been  performed  in 
childhood  by  Pollard/  and  in  early  infancy  by  Bajardi.^ 
The  method  described  is  that  of  Bradford.^ 

Elongation  of  the  Ligamentum  Patellae. 

In  certain  cases  the  ligamentum  patellae  may  be  abnormally 
long,  so  that  the  patella  lies  habitually  above  its  proper  position. 
This  elongation  may  be  one  of  the  evidences  of  general  relaxation 
of  the  ligaments  of  the  knee,  and  thus  a  predisposing  cause  of  the 
slipping  patella  or  of  abnormal  mobility  at  the  knee-joint. 

Etiology.  The  elongation  of  the  tendon  may  be  a  congenital 
peculiarity  or  it  may  be  acquired.  It  is  most  often  observed  as 
an  effect  of  anterior  poliomyelitis  or  of  hemiplegia  or  paraplegia. 

Symptoms.  The  symptoms  of  elongation  of  the  ligamentum 
patellae,  as  distinct  from  those  of  the  general  laxity  of  the  liga- 
ments that  is  often  present,  are  weakness  and  disability,  usually 
noticeable  on  walking  up  or  down  stairs,  or  after  overexertion. 
Shaffer,  who  first  called  attention  to  the  disability  from  this  cause, 
thinks  that  it  may  be  a  predisposing  cause  of  displacement  of  the 
semilunar  cartilages.^ 

Treatment.  In  this,  as  in  other  forms  of  insecurity  or  of 
abnormal  mobility  at  the  knee,  a  brace  that  allows  only  antero- 
posterior motion  will,  as  a  rule,  relieve  the  symptoms.  If  the 
ligament  is  of  such  a  length  as  to  require  it,  it  may  be  shortened, 
or  the  tubercle  of  the  tibia  may  be  removed  and  implanted  at  a 
lower  point,  as  suggested  by  Walsham.^ 

Other  Congenital  Deformities  at  the  Knee. 

Congenital  displacements  are  uncommon.  As  a  rule,  they 
are  incomplete  and  are  caused  by  laxity  of  the  ligaments  and  by 
defective  formation  of  the  bones  or  other  parts.^ 

Snapping  Knee. 

A  very  slight  form  of  partial  recurrent  displacement  is  the 
snapping  or  clicking  knee  not  uncommon  in  early  infancy,  in 
which  the  tibia  on  sudden  extension  of  the  limb  springs  forward 
or  rotates  outward  on  the  femur  with  an  audible  snapping  sound. 

1  Lancet,  1891,  vol.  i.  p.  988.  -  Archiv  di  Ortoped.,  1894,  p.  209. 

3  Transactions  American  Orthopedic  Association,  vol.  viii.  p.  228. 

4  Ibid.,  vol.  xi.  '  Medical  Week,  February  17, 1893. 
6  Drehmann.    Die  Cong.  Lux.  des  Kniegelenks.    Zeits.  f.  Orth.  Chir.,  1900,  Bd.  vii.  H.  4. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT.     439 

This  movement  appears  to  be  the  result  of  voluntary  muscular 
contraction  combined  with  laxity  of  ligaments.  In  some  in- 
stances the  subluxation  appears  to  cause  j)ain  or  discomfort. 
The  ability  to  displace  the  tibia  on  the  femur  by  muscular  action 
is  sometimes  found  in  older  subjects.  Occasionally  the  snapping 
may  be  caused  by  slipping  of  the  biceps  tendon. 

Treatment.  The  treatment  of  congenital  dislocations  or  sub- 
luxations of  the  knee  consists  in  reposition,  support,  and  massage 
of  the  weak  part.  The  snapping  knee  may  be  supported  by  a 
flannel  bandage,  or,  in  the  more  marked  type  of  laxity  of  liga- 
ments, it  may  be  fixed  for  a  time  in  a  brace.  Complete  recovery 
is  the  rule. 

Congenital  Contraction  at  the  Knee. 

Slight  limitation  of  the  range  of  extension  of  one  or  both  knees 
is  not  infrequent.  As  a  rule,  it  is  easily  overcome  by  massage 
and  manipulation.  In  the  more  extreme  cases  there  may  be  an 
accommodative  forward  bending  of  the  lower  extremity  of  the 
femur,  as  in  certain  cases  in  which  flexion  follows  anchylosis. 

General  Contractions. 

Congenital  contraction  at  the  knees  of  a  more  marked  and 
resistant  form  may  be  combined  with  flexion  contraction  at  the 
hips,  or  it  may  be  one  of  a  series  of  contractions  at  other  joints. 
In  the  latter  instance  other  congenital  deformities,  such  as  club- 
hand or  foot,  or  evidences  of  defective  development  are  usually 
present.  For  example,  certain  joints  may  be  fixed  in  flexion  or 
fixed  in  extension.  In  some  instances  the  contraction  or  the  par- 
tial anchylosis  appears  to  be  due  simply  to  long-continued  fixation 
in  liter o,  and  to  consequent  non-development  of  the  muscles.  In 
others  it  appears  to  be  a  complication  of  so-called  foetal  rhachitis. 

Treatment.  The  treatment  consists  in  regular  massage  and 
manipulation,  with  the  aim  of  increasing  the  range  of  motion. 
Deformity,  if  present,  may  be  rectified  in  the  usual  manner. 

Prognosis.  The  prognosis  depends  upon  the  cause  of  the  con- 
traction or  fixation.  In  most  instances,  under  careful  and  con- 
tinued treatment,  the  range  of  motion  may  be  in  great  degree 
restored. 


CHAPTER    XI. 

DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT. 

Tuberculous  Disease  of  the  Ankle-joint. 

Disease  of  the  ankle-joint  is  the  third  in  the  order  of  impor- 
tance, although  it  is  far  less  common  than  is  disease  at  the  knee. 

In  five  consecutive  years  1788  cases  of  tuberculous  disease  of 
the  joints  of  the  lower  extremity  were  treated  at  the  out-patient 
department  of  the  Hospital  for  Ruptured  and  Crippled.  In  54.1 
per  cent,  of  these  the  hip-joint  was  affected  ;  in  36.2  per  cent, 
the  knee-joint,  and  in  but  9.7  per  cent,  the  ankle-joint. 

Fig.  262. 


Tuberculous  disease  of  the  ankle  and  tarsus.    A,  disease  of  the  ankle  and  subastragaloid 
•'oints.    B,  cavity  in  the  os  calcis  containing  sequestrum. 

Pathology.  The  pathology  of  tuberculous  disease  at  the  ankle 
differs  in  no  essential  particular  from  that  of  disease  of  the  hip 
and  knee.  It  does  not,  therefore,  call  for  special  consideration. 
It  is  of  interest  to  note,  however,  that  abscess  is  a  more  common 
complication  at  this  than  at  the  other  joints. 

In  30  final  results  of  disease  at  the  ankle  reported  by  Gibney,  ^ 

1  American  Journal  of  Obstetrics,  April,  1880. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.     441 

abscess  was  present  in  25  (83  per  cent.).  In  78  final  results 
reported  by  Prendlsburger^  abscess  was  present  in  68  (87  per 
cent.),  as  contrasted  with  a  percentage  of  69  and  51  at  the  knee 
and  hip,  respectively.  This  greater  liability  to  abscess  is  very 
possibly  apparent  rather  than  actual,  since  the  ankle-joint  is  so 
superficial  that  fluctuation  may  be  detected  here  that  would  be 
overlooked  at  the  hip.  And  because  the  tissues  about  the  joint 
readily  allow  spontaneous  opening  at  an  early  period,  before 
sufficient  time  has  elapsed  to  permit  of  spontaneous  absorp- 
tion. 

Situation  of  the  Disease.  Otto  Hahn^  has  recently  investigated 
the  cases  of  tuberculous  disease  of  the  ankle  and  foot  treated  at 
Tubingen  during  the  past  fifteen  years.  These  cases  were  704 
in  number  in  685  patients,  in  19  both  feet  having  been  in- 
volved. 

In  309  of  the  cases  the  disease  was  of  the  ankle-joint.  Of 
these  51  per  cent,  were  osteal  in  origin.  The  primary  focus  was 
in  the  internal  malleolus  in  11,  the  external  in  7,  in  both  in  5. 
It  was  in  the  astragalus  in  116  cases. 

In  16  instances  the  disease  of  the  ankle  was  secondary  to 
primary  infection  of  the  os  calcis,  and  in  5  cases  both  the  astrag- 
alus and  the  os  calcis  were  diseased. 

Etiology.  The  etiology  of  tuberculous  joint  disease  does  not 
require  further  comment.  It  may  be  noted,  however,  that  tuber- 
culous disease  at  the  ankle  is  relatively  more  common  in  later 
childhood  and  adult  life  than  is  the  same  affection  at  the  knee 
and  hip. 

Of  1000  cases  of  disease  of  the  hip-joint,  12  per  cent,  were  in 
patients  more  than  ten  years  of  age. 

Of  1000  cases  of  disease  of  the  knee-joint,  25  per  cent,  were 
in  patients  more  than  ten  years  of  age. 

Of  339  cases  of  disease  of  the  ankle-joint,  30  per  cent,  were 
in  patients  more  than  ten  years  of  age.^ 

Of  the  339  patients  177  were  males  (52.2  per  cent.);  162 
were  females  (47.8  per  cent.).  The  disease  was  of  the  right 
ankle  in  173  cases  ;  of  the  left  in  166. 


1  Loc.  cit.  2  Beitrage  zur  klin.  Chir.,  1900,  Bd.  xxvi.  H.  2. 

»  Statistics  from  Hospital  for  Ruptured  and  Crippled. 


442 


OBTHOPEBIG  SUBQEBY. 


Age  at  Incipiency  of  Ankle-joint  Disease  in  339  Consecutive 
Cases  Treated  at  the  Hospital  for  Euptured  and  Crippled. 


1  year  or  less       ....     5 

2  years  old 42 

3  "       "  . 

4  "        "  . 

5  "         "  . 

6  "        "  . 

7  "        "  . 


24  years  old 2 


42 

25 

43 

26 

44 

27 

34 

28 

24 

29 

19 

30 

8 

31 

9 

32 

9 

33 

11 

34 

8 

35 

4 

36 

4 

37 

4 

40 

6 

43 

2 

44 

4 

45 

3 

46 

3 

48 

4 

50 

5 

2 

Of  658  patients  412  were  males  (62  per  cent.);    246  were 
females  (38  per  cent.).     In  27  the  sex  was  not  stated. 


Age  of  the  Patients  Treated  for  Ankle-joint  and  Tarsal 
Disease  at  Tubingen.    (Hahn.) 


1  to  10  years 


20 
30 
40 
50 
60 
70 


Males. 

Females. 

Total 

45 

28 

73 

149 

91 

240 

89 

34 

123 

32 

28 

60 

37 

27 

64 

35 

26 

61 

18 

11 

29 

6 

1 

7 

1 

0 

1 

412 


658 


Symptoms.  The  symptoms  are  usually  subacute  in  character, 
and  are  often  mistaken  for  sprain  or  rheumatism.  In  some 
instances  they  appear  to  follow  an  injury,  but  in  the  majority  of 
cases  in  childhood  no  cause  can  be  assigned.  The  ankle  becomes 
sensitive  to  sudden  movements  ;  the  patient  limps,  and  discomfort 
after  overuse  and  pain  at  night  become  noticeable.  The  limp 
differs  in  character  from  that  caused  by  hip  or  knee  disease. 
The  patient  walks  with  the  foot  rotated  outward,  bearing  the 
weight  upon  the  heel  and  upon  the  inner  border,  active  leverage 
"  spring  "  being  avoided. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.     443 

Deformity.  The  primary  deformity  of  ankle-joint  disease  in 
the  subacute  cases  is  valgus,  induced  apparently  by  the  continued 
use  of  the  limb  in  the  passive  attitude.  In  more  advanced  cases 
it  becomes  equinovalgus,  and  when  the  limb  is  no  longer  capable 
of  supporting  weight,  but  is  held  pendent,  the  equinus  deformity 
predominates,  due  partly  to  the  force  of  gravity  and  partly  to 
the  muscular  spasm. 

Fig.  263. 


*  -^*y'  ,',^   _. 

i 

Tuberculous  disease  of  the  ankle. 


As  has  been  stated,  in  the  early  stage  the  symptoms  are  those 
of  a  persistent,  somewhat  painful  disability  at  the  ankle,  causing 
stiffness,  limp,  and  at  times  jpain ;  later  sivelling  and  deformity 
appear. 

Physical  Examination.  The  joint  is  usually  somewhat  enlarged. 
In  some  instances  the  swelling  is  uniform  ;  in  others  it  is  local- 
ized in  front  or  behind  one  of  the  malleoli.  This  swelling  is  not, 
as  a  rule,  like  that  of  simple  effusion  into  the  joint,  but  the 
tissues  have  the  peculiar  elastic  characteristic  of  thickening  and 
infiltration.  There  is  usually  a  perceptible  increase  in  the  local 
temperature,  and  pressure  directly  upon  the  malleoli  causes  dis- 
comfort.    The  voluntary  movements  of  the  joint  are  restricted. 


444 


ORTHOPEDIC  SURGERY. 


and  passive  movements  show  the  characteristic  reflex  muscular 
spasm,  limiting  both  dorsal  and  plantar  flexion. 

Subastragaloid  Disease.  If  the  astragalus  is  primarily  diseased, 
the  symptoms  are  usually  first  apparent  in  the  ankle-joint,  but  in 
certain  cases  the  joint  between  the  astragalus  and  the  os  calcis  is 
first  involved,  the  primary  focus  being  in  the  os  calcis.  Disease 
at  the  subastragaloid  joint  is  usually  classed  as  ankle-joint  disease, 
although  the  swelling  is  most  marked  at  a  point  somewhat  below 
the  malleoli  (Fig.  264). 


Ftg.  264. 


Tuberculous  disease  of  the  subastragaloid  joint. 


In  this  form  forced  lateral  motion  of  the  os  calcis  causes  dis- 
comfort, and  the  range  of  adduction  and  abduction  of  the  foot 
is  restricted,  while  dorsal  and  plantar  flexion  may  remain  com- 
pletely free. 

Diagnosis.  The  principles  of  differential  diagnosis  of  tuber- 
culous disease  from  other  affections  have  been  considered  in 
detail  in  the  description  of  disease  of  the  spine  and  of  the  larger 
joints. 

In  childhood  a  chronic,  painful  disease  confined  to  a  single 
joint  in  which  motion   is   limited  by   muscular   spasm,  and  in 


Fig.  265. 


The  epiphyses  of  the  lower  extremities  at  the  age  of  six  years,  showing  the  effect  of  oper- 
ative removal  of  bone  at  the  ankle-joint  for  tuberculous  disease  at  the  age  of  three  years,  in 
causing  suteei-juent  deformity  of  the  foot  and  shortening  of  the  limb.  Ossification  is  present 
at  birth  in  the  lower  epiiihysis  of  the  tibia.  It  begins  at  the  second  year  in  the  lower 
epiphysis  of  the  fibula,  but  not  until  tfic  lifth  year  in  its  upper  epiphysis. 


446  ORTHOPEDIC  SURGERY. 

which  there  is  a  tendency  to  deformity,  is  almost  certainly 
tuberculous  in  character. 

In  adult  life  also  the  same  statement  applies,  and  distinguishes 
tuberculous  disease  from  rheumatism,  rheumatoid  arthritis,  or  other 
general  affections.  Forms  of  infectious  arthritis  may  be  dift'er- 
entiated  by  the  history.  Sprains  or  other  injury  may  be  distin- 
guished by  the  history  of  the  onset  and  by  the  absence  of  local 
signs  of  serious  disease.  In  rigid  flat-foot  the  symptoms  are  local- 
ized at  the  mediotarsal  joint.  It  should  be  borne  in  mind,  also, 
that  the  pain  from  a  weak  or  injured  foot  is  experienced,  as  a 
rule,  only  when  it  is  in  use ;  whereas,  in  tuberculous  disease  of 
the  bone,  pain  is  common  when  the  part  is  not  in  use,  and  it 
may  be  particularly  troublesome  at  night. 

Treatment.  In  disease  of  this,  as  of  other  joints,  functional 
rest  is  indicated.  This  necessitates  fixation  of  the  joint  and 
stilting  of  the  limb,  efficient  traction  being  manifestly  impossible. 
The  foot  should  be  fixed  in  a  light  plaster  bandage,  extending 
from  the  extremities  of  the  toes  to  the  calf,  at  a  right  angle  with 
the  leg  and  in  an  attitude  of  slight  supination,  in  order  to  guard 
against  the  tendency  toward  valgus.  This  deformity  is  very 
common  after  the  cure  of  the  disease,  and  it  often  subjects  the 
patient  to  the  additional  discomfort  of  progressive  flat-foot. 

Reduction  of  Deformity.  If  the  foot  has  become  distorted 
before  the  patient  is  brought  for  treatment,  the  plaster  bandage 
may  be  applied  in  the  attitude  of  deformity,  and  at  the  subse- 
quent applications  of  the  dressing,  when  the  muscular  spasm  is 
lessened,  gentle  manipulation  will  gradually  overcome  the  mal- 
position. In  resistant  cases  immediate  reduction  of  the  deformity 
under  anaesthesia  may  be  advisable.  Throughout  the  entire 
course  of  treatment  the  greatest  attention  must  be  paid  to  the 
attitude.  Deformity  is  easily  prevented,  but  is  often  very  diffi- 
cult to  correct,  especially  during  the  later  stages  of  the  disease, 
when  the  tissues  are  infiltrated  and  sensitive,  and  especially  if 
discharging  sinuses  are  present. 

Other  retentive  appliances  may  be  employed,  but  they  are 
inferior  to  a  properly  applied  bandage,  which  holds  its  place  by 
accuracy  of  adjustment,  which  most  effectively  prevents  motion, 
and  which  exercises  a  certain  degree  of  compression  upon  and 
general  support  of  the  swollen  joint.  The  bandage  is  usually 
renewed  at  intervals  of  a  month,  but  it  may  be  retained  indefi- 
nitely if  it  is  properly  protected  by  a  light  shoe  or  slipper.  The 
Bier  method  of  passive  congestion  may  be  applied  at  the  ankle 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.     447 

by  means  of  a  bandage  above  the  upper  border  of  the  plaster 
support.  A.nd  the  adhesive  plaster  strapping  may  be  used 
beneath  the  plaster  bandage  if  local  compression  and  more 
comprehensive  support  is  desired. 

The  most  satisfactory  brace  to  serve  as  a  stilt  in  connection 
with  the  local  support  is  the  Thomas  brace,  which  has  been 
described  in  the  section  on  disease  of  the  knee-joint  (Fig. 
258). 

When  patients  are  treated  efficiently  the  discomfort  or  incon- 
venience attending  the  disease  is  slight.  As  a  rule,  the  swelling 
of  the  joint  becomes  more  localized  and  finally  an  abscess  appears 
beneath  the  skin.  It  is  then  advisable  to  remove  the  fluid  and 
other  contents  by  means  of  a  simple  incision.  In  most  instances 
a  sinus  persists  for  a  time.  If  the  discharge  is  slight,  the  part 
may  be  dressed  with  ichthyol,  balsam  of  Peru  or  other  applica- 
tion, and  the  whole  inclosed  again  in  the  plaster  bandage ;  or,  if 
it  be  more  profuse,  an  opening  may  be  made  and  the  dressing 
applied  outside  the  plaster  bandage. 

Operative  Treatment.  Early  operation,  especially  of  a  gouging 
character,  should  be  avoided.  An  effective  operation  of  this 
class  often  involves  the  sacrifice  of  bone  that  would  be  spared 
in  the  natural  cure,  and  it  entails  an  irregularity  in  the  growth 
and  causes  deformity  in  after-life  that  may  be  irremediable  (Fig. 
265). 

Similar  operations  in  the  treatment  of  fistulse,  or  abscess,  while 
the  tissues  are  thickened  and  oedematous,  and  while  the  disease 
within  the  joint  is  active,  should  be  postponed  until  the  process 
of  repair  is  more  advanced.  During  the  stage  of  convalescence, 
however,  cure  may  be  hastened  by  the  removal  of  persistent  foci 
of  disease,  or  sequestra  in  the  bone,  or  tuberculous  tracts  in  the 
overlying  soft  parts. 

In  the  adult  or  adolescent,  and  in  exceptional  cases  in  child- 
hood, operative  removal  of  the  disease  may  be  indicated.  If  it 
is  confined  to  the  ankle-joint,  the  removal  of  the  astragalus, 
which  is  usually  the  primary  seat  of  infection,  is  the  operation  of 
choice. 

The  operation  is  performed  under  the  Esmarch  bandage  ;  a 
curved  lateral  incision  is  made  passing  beneath  the  external 
malleolus  from  the  neighborhood  of  the  tendo  Achillis  to  the 
anterior  aspect  of  the  joint.  The  lateral  and  capsular  ligaments 
are  divided,  after  which  the  foot  may  be  displaced  inward.  The 
astragalus  is  exposed  and  it  may  be  removed  easily  by  dividing 


448  ORTHOPEDIC  S UB GEB  Y. 

the  ligaments  about  its  head  and  its  attachment  to  the  os  calcis. 
All  the  diseased  tissue  in  the  soft  parts  and  in  the  bone  must  be 
removed  thoroughly.  If  the  disease  has  not  extended  to  the 
tarsus,  and  if  it  seems  to  have  been  completely  removed,  the 
wound  may  be  closed,  but  in  most  cases  it  should  be  packed  for 
a  time  with  gauze.  The  after-treatment  is  conducted  as  if  the 
operation  had  not  been  performed,  support  and  fixation  being 
continued  until  it  is  evident  that  the  disease  is  cured. 

Removal  of  the  astragalus  does  not  interfere  to  a  marked  extent 
with  the  function  of  the  foot,  nor  does  it  cause  noticeable  de- 
formity. As  a  primary  operation,  permitting  inspection  and  the 
opportunity  for  thorough  removal  of  all  disease  in  the  neighbor- 
ing parts,  it  should  always  be  performed  in  preference  to  exten- 
sive gouging,  which  is,  as  a  rule,  of  little  avail. 

Prognosis.  Disease  at  the  ankle  is  not  only  less  common,  but 
it  is  less  dangerous  than  that  of  the  larger  joints,  because  it  is 
remote  from  important  structures,  and  because  there  is  less 
opportunity  for  the  burrowing  of  infected  abscesses.  The  dura- 
tion of  the  disease  here  is,  as  a  rule,  shorter  than  at  the  knee  or 
hip,  and  the  final  results  in  childhood  are  almost  always  excel- 
lent. Often  free  motion  is  retained  at  the  ankle,  and  even  if  the 
astragalus  be  fixed  by  disease  the  mobility  in  the  other  joints  of 
the  foot  is  sufficient  to  compensate  very  effectively  for  the 
anchylosis.  Shortening  of  the  limb  is  of  comparatively  little 
consequence.  It  is  not  often  more  than  an  inch,  and  it  may  be 
absent.  The  growth  of  the  foot  is  often  considerably  retarded, 
partly  from  disuse  and  partly  because  of  the  destructive  effect 
of  the  disease  upon  the  tarsal  bones. 

In  the  30  cases  reported  by  Gibney,  treated  expectantly,  in 
which  the  mechanical  treatment  was  far  from  effective,  6  patients 
recovered  with  normal  motion ;  1 1  with  practically  normal  func- 
tion. In  7  there  was  good  motion.  In  6  there  was  anchylosis, 
and  in  3  persistent  valgus.  In  all  the  limb  was  efficient.  In  20 
instances  there  was  no  limp,  and  in  but  1  case  was  it  marked. 
In  no  instance  was  a  crutch,  cane,  or  other  support  used.  The 
average  duration  of  the  disease  was  three  years  and  three  months, 
a  minimum  of  one  year,  a  maximum  of  six  years.  There  were 
2  deaths,  of  which  but  1  was  dependent  upon  the  disease,  septi- 
caemia being  the  cause  assigned,  though  it  is  stated  that  practically 
all  the  bones  of  the  tarsus  were  involved.  In  this  case  amputa- 
tion was  evidently  indicated. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.     449 


Tuberculous  Disease  of  the  Tarsus. 

Tuberculous  disease  of  the  joints  of  the  foot,  not  involving  the 
ankle,  is  not  uncommon. 

In  386  of  the  704  cases  reported  by  Hahn,  the  disease  was 
limited  to  the  foot.  In  141  cases  the  mediotarsal  joint  was 
involved;  in  51  of  these  the  disease  was  confined  to  this  joint; 
in  46  the  ankle  was  involved ;  in  29  the  disease  extended  for- 
ward to  the  tarsometatarsal  articulation,  and  in  16  the  three 
joints  were  diseased.  In  78  cases  the  tarsometatarsal  joint  was 
involved,  in  33  of  which  the  disease  did  not  extend  beyond  this 
articulation. 

Disease  of  Individual  Bones.  In  these  cases  the  distribution 
was  as  follows  : 


The  astragalus 
The  calcaneum 
The  cuboid 
The  scaphoid    . 
The  cuneiform  bones 


170 ;  disease  confined  to  the  single  bone  in   8 
200;        "  "  "  "  "      87 

116;        "  "  "  "  "      18 

82;        "  "  "  "  "       2 


Metatarsal  bones 45 ; 


in  one-half  of  these  the  disease  was 
of  the  first  metatarsal,  either  alone 
or  in  connection  with  the  adjoin- 
ing cuneiform  hone  or  phalanx. 


In  a  total  of  1231  cases,  including  these  and  others  reported 
by  Audry,'^  Koenig,^  Mondan,^  Munch,*  Spengler,^  Vallas,^ 
Czerny,^  and  Dumont,^  the  relative  frequency  of  the  disease  in 
the  bones  of  the  foot  and  ankle  appeared  to  be  as  follows  : 


Malleoli 

96,    7.7  per  cent. 

Scaphoid     . 

.    110,  8.9  per  cent. 

Astragalus    . 

.    291,  23.6 

Cuneiform  bones 

.    109,  8.8 

Calcaneus    . 

.    339,  25.9 

Metatarsus  . 

.    no,  8.9 

Cuboid 

Tt.' Tk. 

.     154,  12.5 

-If     a.1-  .        A   ..J. 

Phalanges  . 

.      22,  1.7 

Primary  Disease  of  the  Astragaloscaphoid  Joint.  In  dis- 
ease at  this  point  the  swelling  is  localized  in  front  of  the  ankle 
on  the  inner  side  of  the  foot.  Adduction  is  restricted,  and  the 
foot  is  often  fixed  in  an  attitude  of  persistent  abduction. 

Disease  of  other  bones  of  the  tarsus  is  indicated  by  the  local 
swelling  and  sensitiveness.  The  disease  sometimes  involves  the 
shaft  of  a  metatarsal  bone,  or  one  of  the  phalanges,  causing 
expansion  and  destruction,  "  spina  ventosa." 

Treatment  of  Tarsal  Disease.  Disease  of  the  tarsus  shows 
a  marked  tendency  to  extend  from  one  bone  to  another  until  the 
entire  foot  is  involved.     Consequently   if  an  early  diagnosis  is 


1  Revue  de  Chir.,  1891. 
"  Deutsche  Chir.,  1.  66. 
5  Ibid  ,  1897,  Bd.  xliv. 
"  Volk.  S.  klin.,  v..  No.  76. 


2  Schmidt's  Jahrb.,  1884,  Bd.  cciv. 
*  Deutsche  Zeits.  f  Chir.,  1879,  Bd.  xi. 
«  Deutsche  Chir.,  1.,  66. 
»  Deutsche  Zeits.  f.  Chir.,  1882,  Bd.  xvii. 


29 


450  ORTHOPEDIC  SURGERY. 

made  of  a  distinctly  localized  process  prompt  removal  of  the  dis- 
eased bone  is  indicated  ;  but  in  most  instances  the  disease  is  too 
extensive  to  permit  of  its  radical  removal.  In  such  cases  opera- 
tive intervention  is  contra  indicated,  and  the  treatment  by  protec- 
tion, similar  to  that  employed  in  disease  of  the  ankle,  is  indicated. 
In  childhood  the  prognosis  is  very  good  even  when  the  disease  is 
extensive,  but  in  adult  life  amputation  of  the  foot  may  be  advis- 
able because  of  the  time  required  to  assure  a  natural  cure  and 
because  an  artificial  leg  provides  a  better  support  than  a  stiff  and 
sensitive  extremity.  Amputation  is  almost  always  indicated, 
if  there  is  co-existent  disease  of  the  lungs. 

Sprain  of  the  Ankle. 

The  ankle  is,  from  its  position,  especially  liable  to  injury  ;  in 
fact,  the  term  "  sprain  "  is  popularly  associated  with  this  joint. 

A  sprain  is  most  often  caused  by  an  unguarded  movement,  by 
which  the  foot  is  turned  suddenly  inward  or  outward,  with  suffi- 
cient force  to  injure  the  synovial  membrane,  to  rupture  some  of 
the  fibres  of  the  muscles,  to  strain  tendons  and  tendon  sheaths, 
and  even  to  rupture  ligaments.  If  the  foot  is  twisted  inward 
the  injury  is  most  marked  on  the  outer  side  of  the  joint ;  if  out- 
ward, on  the  inner  side  of  the  ankle.  In  the  slighter  degrees  of 
sprain  the  injury  may  be  confined  to  the  tissues  about  the  joint, 
but  in  most  instances  there  is  effusion  within  the  capsule,  even 
hemorrhage  when  the  injury  has  been  severe. 

Symptoms.  The  immediate  symptoms  of  sprain  are  pain, 
often  intense,  of  a  throbbing  character,  swelling,  heat,  and  in 
many  instances  discoloration  of  the  surrounding  parts,  even 
extending  over  the  leg  and  foot. 

Treatment.  If  an  opportunity  for  immediate  treatment  is 
offered,  the  swelling  and  the  effusion  of  blood  may  be  restrained 
by  the  application  of  elastic  stockinette  bandages  from  the  toes 
to  the  knee.  As  much  compression  is  exercised  as  the  comfort 
of  the  patient  will  allow,  and  the  bandage  should  be  made  suffi- 
ciently thick  to  prevent  painful  motion.  If  the  injury  has  been 
severe  and  if  the  part  is  very  sensitive  to  motion  or  jar,  the  joint, 
having  been  protected  with  cotton,  may  be  fixed  in  a  light  plaster 
bandage.  This  may  be  cut  down  the  front  to  allow  for  daily 
massage  of  the  foot,  ankle,  and  leg  which  is  of  great  service  in 
hastening  the  absorption  of  the  effusion. 

The  use  of  hot  air,  hot  and  cold  water,  and  static  electricity, 
and  the  like  are  of  service  also  in  relieving  the  discomfort  and 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.     451 

especially  in  stimulating  the  circulation  of  the  blood,  upon  which 
repair  depends. 

By  far  the  most  effective  treatment  during  the  stage  of  recovery 
and  as  an  immediate  application  for  sprains  of  slighter  degree,  is 
the  adhesive  plaster  strapping  which  has  been  popularized  by 
Gibney.  His  method  is  as  follows  :  Strips  of  adhesive  plaster 
about  three-quarters  of  an  inch  in  width  and  from  nine  to  eighteen 
inches  in  length  are  prepared.  A  long  strip  is  placed  with  its 
centre  beneath  the  heel,  and  the  two  ends  are  carried  upward 
over  the  malleoli,  to  a  point  at  the  junction  of  the  middle  and 
lower  thirds  of  the  leg.  A  second  strip  is  placed  at  the  pos- 
terior extremity  of  the  heel,  and  the  two  ends  are  carried  for- 
ward somewhat  beyond  the  tarsometatarsal  junction  on  either 

Fig.  266. 


A  method  of  applying  adhesive  plaster  strapping  for  sprain  of  the  ankle. 

side.  Another  strip  is  then  placed  by  the  side  of  the  first,  and 
the  fourth  by  the  side  of  the  second,  until  the  entire  ankle  is 
smoothly  covered,  except  for  a  space  about  two  inches  in  width 
directly  on  the  front  of  the  ankle.  One  takes  particular  care  to 
make  the  plaster  fit  well  about  the  malleoli  and  reinforces  it  at 
the  points  of  greatest  sensitiveness.  A  light  bandage  is  then 
applied  and  the  patient  is  encouraged  to  use  the  foot  in  walking. 
The  plaster  may  be  applied  in  a  variety  of  ways  ;  a  satisfactory 
method  is  as  follows,  after  the  preliminary  massage  for  the  pur- 
pose of  reducing  the  swelling  : 

One  end  of  a  strip  of  adhesive  plaster  about  three  feet  long 
and  three  inches  wide  is  applied  to  the  lateral  aspect  of  the  leg 
just  below  the  knee-joint ;  it  is  carried  down  the  side  of  the  leg 


452  ORTHOPEDIC  SURGERY. 

over  the  malleolus,  beneath  the  heel  and  arch,  and  up  the  other 
side  to  a  point  opposite  the  beginning,  where  it  is  fixed  by  a  cir- 
cular band  about  the  calf.  If  the  sprain  is  of  the  outer  side  of 
the  ankle,  sufficient  tension  is  made  upon  the  outer  half  of  the 
plaster  to  hold  the  foot  slightly  abducted.  If,  as  is  more  common, 
the  sprain  is  of  the  inner  side,  the  inner  half  is  drawn  firmly 
beneath  the  arch,  carrying  the  foot  toward  inversion  so  that  all 
strain  may  be  removed  from  the  sensitive  part.  This  band  of 
plaster  is  reinforced  by  one  or  more  so  that  the  lateral  aspect  of 
the  ankle  is  completely  covered.  And  in  addition  the  entire 
ankle  is  then  inclosed  with  narrow,  overlapping  strips  which  cover 
all  the  tissues  well  beyond  the  sensitive  area.     The  foot  and  leg 

Fig.  267. 


The  stockinette  bandage. 

are  then  bandaged  to  assure  the  adhesion  of  the  plaster.  When 
the  joint  is  firmly  held  by  the  supporting  plaster  the  patient  can, 
as  a  rule,  walk  with  comfort ;  and  he  is  encouraged  to  do  so,  for 
functional  use,  provided  it  does  not  cause  additional  injury,  is 
the  most  effective  stimulant  of  the  circulation  ;  thus  the  patient 
applying,  as  it  were,  an  automatic  massage,  cures  himself. 

As  the  swelling  subsides  the  plaster  strapping  wrinkles,  and  it 
must  be  renewed,  about  three  applications  being  required,  as  a 
rule,  the  last  of  which  is  allowed  to  remain  until  all  of  the  symp- 
toms have  disappeared.  Vigorous  massage  before  applying  the 
new  dressing  is  of  service  in  hastening  the  cure.  It  is  perhaps 
needless  to  state  that  a  preliminary  shaving  of  the  part  will  add 
somewhat  to  the  comfort  of  the  patient. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.      453 

Chronic   Sprain. 

A  chronic  sprain  may  be  the  result  of  an  inefficiently  treated 
acute  injury,  in  which  an  improper  attitude  originally  assumed 
to  spare  the  sensitive  part  finally  becomes  habitual.  In  other 
instances  persistent  disability  may  be  the  result  of  fixation  of  the 
joint  for  too  long  a  time  in  splints.  Such  disuse  causes  atrophy 
of  the  muscles  and  of  the  bones  as  well  (see  Atrophy,  page  241), 
while  the  effused  material  within  and  without  the  joint  remains 
because  of  the  imperfect  circulation.  The  same  disability  may 
follow  simple  disuse  of  the  injured  part.  It  is  more  often 
observed  in  nervous  individuals  who  exaggerate  the  importance 
of  the  injury  and  the  discomfort  that  it  causes.  In  such  cases 
the  limb  may  be  discolored  by  venous  congestion,  the  foot  may 
be  cedematous,  and  the  movements  may  be  limited  by  adhesions 
or  by  muscular  adaptation  to  the  habitual  attitude. 

In  other  instances  the  original  injury  may  have  caused  a  slight 
subluxation  of  the  astragalus,  sufficient  to  throw  the  foot  into  an 
attitude  of  abduction,  in  which  it  has  become  fixed  by  the  second- 
ary changes  in  the  muscles  and  ligaments.  In  some  cases  of 
this  class  the  original  sprain  was  at  the  mediotarsal  or  at  the  sub- 
astragaloid  joint,  and  its  effect  has  been  traumatic  weak  foot. 
It  may  be  stated,  also,  that  many  of  the  so-called  sprains  of  the 
ankle  are  simply  injuries  of  a  weak  foot,  a  disability  to  which 
the  treatment  should  be  directed.     (See  the  Weak  Foot.) 

Treatment.  Treatment  must  be  conducted  with  the  aim  of 
restoring  the  normal  range  of  motion  and  so  supporting  the  part 
that  normal  functional  use  may  be  permitted.  If  adhesions  have 
formed  and  if  the  foot  is  persistently  held  in  an  abnormal  atti- 
tude, forcible  manipulation  under  anaesthesia  may  be  required  as 
a  preliminary  treatment,  followed  by  fixation  for  a  time  in  a 
plaster  bandage,  in  the  attitude  directly  opposed  to  that  which 
has  been  habitual.  In  this  class  of  cases  the  habitual  attitude  is 
usually  one  of  equinovalgus  ;  the  foot  should  be  fixed  for  a  time, 
therefore,  in  a  plaster  bandage  in  a  position  of  extreme  varus, 
at  a  right  angle  with  the  leg,  and  upon  it  the  patient  is  encour- 
aged to  bear  his  weight  both  in  standing  and  walking.  When 
all  discomfort  has  disappeared,  a  support,  usually  a  light  leg 
brace  to  prevent  lateral  motion,  and  if  the  arch  is  depressed  a 
foot  plate  also,  should  be  worn  for  a  time.  The  most  effective 
curative  agent  is  functional  use,  but  massage,  hot  air,  passive 
manipulation,  and  exercises  are  valuable  accessories. 


454 


ORTHOPEDIC  SURGERY . 


Injuries  of  this  class  are  very  amenable  to  treatment,  con- 
ducted with  the  aim  of  restoring  normal  function,  if  proper  sup- 
port is  provided  during  the  period  of  pain  and  weakness. 

Tenosynovitis. 

The  sheaths  of  the  tendons  about  the  ankle-joint,  if  involved 
in  a  sprain  of  the  ankle,  may  cause  persistent  interference  with 


Fig.  268. 


Fig.  269. 


The  internal  annular  ligament  of  the  ankle  and  the  arti- 
ficially distended  synovial  membranes  of  the  tendons 
which  it  confines.    (Testut,  from  Gerrish's  Anatomy.) 

Fig.  270. 


The  anterior  annular  ligament  of  the 
ankle  and  the  synovial  membranes  of 
the  tendons  beneath  it  artificially  dis-  The  external  annular  ligament  of  the  ankle  and  the  arti- 
tended.  (Testut,  from  Gerrish's  Anat-  ficially  distended  synovial  membranes  of  the  tendons 
omy.)  which  it  confines.    (Testut,  from  Gerrish's  Anatomy.) 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT.     455 

function  ;  or  strain  of  a  tendon  and  of  its  sheath  may  cause 
symptoms  of  disability  when  the  joint  is  uninjured.  The  symp- 
toms of  acute  tenosynovitis  are  discomfort  on  motion  of  the 
affected  tendon,  and  this  motion  may  be  accompanied  by  a  pecu- 
liar creaking  which  is  apparent  on  palpation.  In  many  instances 
there  is  slight  local  swelling  and  sensitiveness  to  pressure  about 
the  affected  part,  and  the  general  movements  of  the  foot  that 
call  the  muscle  into  action  are  painful. 

The  arrangement  of  the  tendon  sheaths  should  be  borne  in 
mind.  At  the  ankle-joint  all  the  tendons  are  provided  with 
sheaths;  on  the  front  of  the  foot  are  three — the  sheath  of  the 
tibialis  anticus,  which  extends  from  a  point  about  two  inches 
above  the  extremity  of  the  malleolus  to  the  scaphoid  bone  (Fig. 
268)  ;  that  of  the  extensor  longus  hallucis,  from  the  annular  liga- 
ment to  the  head  of  the  first  metatarsal,  and  the  common  sheath 
for  the  extensor  communis  digitorum,  extending  from  a  point 
about  half  an  inch  above  the  malleoli  to  about  one  inch  below 
the  annular  ligament.  Behind  the  internal  malleolus  are  the 
common  sheaths  of  the  tibialis  posticus  and  flexor  longus  digi- 
torum, beginning  about  an  inch  above  the  extremity  of  the  mal- 
leolus and  extending  to  the  astragaloscaphoid  junction,  and  that 
of  the  flexor  longus  hallucis  of  about  the  same  extent  (Fig.  269). 
Behind  the  outer  malleolus  is  the  sheath  of  the  two  peronei, 
beginning  one  inch  above  the  malleolus,  dividing  into  two  portions 
for  the  two  tendons  and  ending  just  behind  the  tuberosity  of  the 
fifth  metatarsal  bone  (Fig.  270). 

Treatment.  Simple  traumatic  tenosynovitis  should  be  treated 
by  rest  and  by  compression.  An  effective  treatment  is  strapping 
with  adhesive  plaster,  so  applied  as  to  prevent  the  movements  of 
the  foot  that  cause  discomfort.  In  more  painful  and  persistent 
cases  the  use  of  a  plaster  bandage  to  assure  absolute  rest  may  be 
necessary.  Cautery  applied  over  the  affected  part  is  of  service. 
Chronic  tenosynovitis  may  follow  injury  or  it  may  be  the  result 
of  gonorrhoea  or  other  infectious  disease.  In  chronic  cases  when 
the  palliative  treatment  is  ineffective,  thorough  removal  of  the 
affected  sheath  is  indicated.     (See  Achillobursitis.) 

Tuberculous  Tenosynovitis.  A  persistent  and  increasing 
swelling  of  a  tendon  sheath  always  suggests  tuberculous  disease. 
In  such  instances  the  sac  is  thickened  and  often  contains  the 
so-called  rice  bodies.  Prompt  and  complete  removal  of  the  dis- 
eased sheath  is  indicated,  and  by  this  means  a  permanent  cure 
may  be  attained  in  most  instances. 


456  OB THOPEDIC  S  UR GEB  Y. 

Other  Affections  of  the  Ankle-joint. 

The  ankle-joint  may  be  the  seat  of  an  infectious  arthritis  ;  it 
may  be  involved  in  an  osteomyelitis  of  the  tibia.  It  may  be  one 
of  the  joints  affected  in  chronic  rheumatism  or  rheumatoid 
arthritis,  and  occasionally  Charcot's  disease  may  appear  in  this 
situation.  The  principles  of  the  treatment  of  these  affections 
have  been  indicated  elsewhere. 


CHAPTER    XII. 

DISEASES  AND  INJUEIES  OF   THE  ARTICULATIONS  OF  THE 
UPPER  EXTREMITY. 

Tuberculous  Disease  of  the  Shoulder-joint. 

Disease  at  the  shoulder  is  very  uncommon  in  childhood.  In 
a  total  of  453  cases  of  tuberculous  disease  treated  at  the  Vander- 
bilt  clinic  210  were  cases  of  Pott's  disease.  In  6  of  the  remain- 
ing 243  cases  the  disease  was  of  the  shoulder-joint  (2.5  per  cent.). 

In  1883  consecutive  cases  of  joint  disease — Pott's  disease  being 
excluded — treated  in  the  out-patient  department  of  the  Hospital 
for   Ruptured    and   Crippled   during   the   past    five   years,    the 

Fig.  271. 


IV 


Section  of  the  shoulder-joint  at  the  age  of  eight  years.  (Schuchardt )  Ossification  appears 
in  the  epiphysis  of  the  head  of  the  humerus  at  the  end  of  the  first  year ;  a  second  point 
appears  in  the  greater  tuberosity  during  the  second  year.  These  unite  between  the  fourth 
and  sixth  years.    Ossification  is  complete  between  the  eighteenth  and  twentieth  years. 

shoulder -joint  was  involved  in  38  instances  (2  per  cent.).  In 
1900  cases  of  joint  disease  treated  at  Billroth's  clinic,  the  shoulder 
was  involved  in  14,  or  less  than  1  per  cent. 

Pathology.  The  disease  usually  begins  in  the  head  of  the 
humerus.  In  32  observations  on  adults  recorded  by  Mondan  and 
Andry,^  the  primary  disease  was  of  the  head  of  the  humerus  in 
23  cases,  of  the  humerus  and  scapula  in  4,  of  the  scapula  alone 
in  1,  and  in  3  instances  it  appeared  to  be  primarily  synovial. 

1  Revue  de  Chir.,  1892. 


458  OB THOPEDIG  8  UB  QEB  Y. 

In  the  majority  of  cases  abscess  forms  and  comes  to  the  surface 
near  the  insertion  of  the  deltoid  muscle.  In  advanced  cases  the 
tissues  of  the  axilla  and  of  the  adjoining  thorax  may  be  infiltrated 
and  perforated  by  numerous  sinuses.  Not  infrequently  the  dis- 
ease is  of  the  form  called  caries  sicca,  in  which  there  is  no 
swelling,  but  progressive  destruction  of  the  head  of  the  humerus 
by  granulation  tissue.  This  form  is  characterized  by  extreme 
muscular  atrophy  and  by  practical  anchylosis. 

Statistics. 

Age  at  Incipiency  of  Disease  at  the  Shoulder-joint  in  Sixty- 
two  Consecutive  Cases  Treated  at  the  Hospital  for  Rup- 
tured and  Crippled. 


1  year  or  less 

.    1 

13  years  old 

.    3 

2  years  old   . 

.    6 

15           "            .        . 

.    2 

3           "... 

.    1 

18           "            .        . 

.    3 

4          "... 

.     3 

19           "            .        . 

.    5 

5          "... 

.     3 

20           "            .        . 

.    4 

6           "... 

.     1 

23           "            .        . 

.    1 

7           "... 

.     3 

26            •'             .        . 

.    2 

8           "... 

.     4 

27            "             .        . 

.    1 

9           "... 

.     6 

34            "             .        . 

.    1 

10           "        .       .       .     . 

.     1 

48            "             .        . 

.    1 

11           "... 

.     5 

56            "             .        . 

.    1 

12           "... 

.     4 

_ 

Total        .       .       .       .62 
Males,  38 ;  females,  24  ;  right,  35 ;  left,  27. 

Townsend^  made  a  detailed  report  on  21  cases  treated  at  the 
Hospital  for  Ruptured  and  Crippled  during  the  years  1889  to 
1893.  Ten  of  these  were  less  than  ten  years  of  age  ;  7  were 
between  ten  and  twenty,  and  4  were  more  than  twenty.  The 
youngest  patient  was  three  and  a  half  and  the  age  of  the  oldest 
was  thirty-five  years.  In  5  cases  the  disease  was  secondary  to 
disease  of  other  parts  ;  in  1  case  to  Pott's  disease  ;  in  2  to  hip 
disease,  and  in  2  to  disease  of  the  knee-joint. 

Symptoms.  The  history  of  the  case  will  show  the  persistent 
and  progressive  character  of  the  disability,  but  the  symj)toms 
characteristic  of  tuberculous  disease  are  far  less  marked  at  the 
shoulder  than  at  other  joints.  This  is  explained  by  the  fact  that 
the  upper  extremity  is  not  subjected  to  weight  bearing  and  be- 
cause the  mobility  of  the  scapula  upon  the  thorax  lessens  the 
injury  caused  by  unguarded  movements  of  the  arm.  This  double 
joint  at  the  shoulder  masks  the  interference  with  the  function  of 
the  joint,  and  the  strain  caused  by  overuse  may  be  lessened  by 
the  unconscious    restraint  that  the  patient  can    exercise    upon 

1  Transactions  of  the  American  Orthopedic  Association,  vol.  vii. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.    459 

motion  at  this  joint.  In  fact,  even  when  absolute  anchylosis  is 
present  the  patient  may  think  that  motion  is  but  moderately 
restricted. 

The  symptoms  of  the  disease  may  be  classified  as  jjain,  sensi- 
tiveness, restriction  of  motion,  atrophy. 

There  is  usually  a  dull  ache  about  the  joint,  with  occasional 
neuralgic  pain  referred  to  the  elbow  and  arm.  The  discomfort 
is  increased  by  movements  that  pass  beyond  the  limits  allowed 
by  the  mobility  of  the  scapula,  especially  on  attempting  to  rotate 
the  humerus,  as  in  clothing  one's  self  or  brushing  the  hair.  The 
joint  is  sensitive  to  pressure  ;  thus  the  patient  finds  that  he  cannot 
lie  on  the  affected  side  at  night. 

The  normal  range  of  motion  between  adduction  and  abduction 
is  about  90  degrees,  and  between  flexion  and  extension  somewhat 
less. 

On  examination  the  limitation  of  motion  caused  by  muscular 
spasm  will  be  evident  when  the  scapula  is  fixed,  so  that  movement 
of  the  joint  can  be  tested. 

Pressure  upon  the  head  of  the  humerus  usually  causes  pain, 
and  in  many  instances  local  heat  and  swelling  are  present.  The 
atrophy  of  the  shoulder  muscles  is  often  extreme  and  that  of  the 
other  muscles  of  the  limb  is  well  marked. 

As  has  been  stated,  abscess  is  a  common  accompaniment  of  the 
disease,  and  in  such  cases  the  tissues  about  the  joint  are  swollen 
and  infiltrated.  In  other  instances  there  is  progressive  destruc- 
tion of  the  head  of  the  humerus  without  abscess  formation  (caries 
sicca).  In  cases  of  this  type  the  flattening  of  the  shoulder  may 
be  so  extreme  as  to  be  mistaken  for  subcoracoid  dislocation. 

Treatment.  The  treatment  of  the  disease  here  as  elsewhere 
is  rest.  To  assure  absolute  functional  rest  the  wrist  should  be 
attached  to  the  neck  by  a  sling,  the  elbow  being  flexed  to  an 
acute  angle ;  the  arm  is  then  fixed  to  the  thorax  by  a  bandage, 
and  all  the  clothing,  including  the  shirt,  is  placed  outside  the 
affected  part.  Local  rest  and  compression  may  be  still  further 
assured  by  strips  of  adhesive  plaster  applied  over  the  shoulder 
and  extending  to  the  back  and  chest ;  or  a  shoulder  cap  of  leather 
or  plaster  may  be  employed.  This  method  of  fixing  the  arm  is 
the  only  one  that  assures  continuous  rest,  as  a  change  of  the 
clothing  necessitates  movement  of  the  joint.  During  the  acute 
phases  of  the  disease  the  arm  may  be  supported  in  the  attitude  of 
extreme  abduction  by  means  of  a  triangular  splint  or  pad.  This 
position  is  often  that  of  greatest  comfort  to  the  patient.     Direct 


460  ORTHOPEDIC  S UB GEB  Y. 

traction  is  not  often  employed,  as  support  of  the  pendent  limb  is 
usually  preferred  by  the  patient. 

Operative  Treatment.  If  the  focus  of  disease  seems  to  be  local- 
ized, an  exploratory  operation  for  its  early  removal  may  be 
indicated.  Excision  of  the  joint  in  the  adult  cases,  or  arthrec- 
tomy  in  younger  subjects,  may  be  advisable  when  suppuration  is 
persistent  or  when  for  other  reasons  it  may  seem  best  to  attempt 
to  remove  the  diseased  area. 

Prog'nosis.  The  duration  of  the  disease  appears  to  be  from 
two  to  five  years.  The  death-rate  is  higher  than  in  disease  of 
the  joints  of  the  lower  extremity,  because  a  larger  proportion  of 
the  patients  are  adults,  and  in  this  class  tuberculosis  of  the  lungs 
is  not  an  infrequent  complication. 

It  is  impossible  to  speak  positively  of  the  results  of  the  con- 
servative treatment  of  disease  of  the  shoulder.  The  disease  is 
uncommon,  and  protection  is  almost  never  applied  in  the  in- 
cipient stage,  nor  efficiently  and  persistently  employed  to  the 
end.  The  ordinary  result  is,  therefore,  anchylosis,  usually  of 
the  fibrous  rather  than  of  the  bony  variety. 

If  the  disease  appears  in  early  life  the  growth  of  the  limb  may 
be  seriously  interfered  with  -,  an  inch  or  more  of  shortening  from 
this  cause  is  not  uncommon. 

Tuberculous  Disease  of  the  Elbow-joint. 

Tuberculous  disease  of  the  elbow-joint  is  the  fourth  in  order 
of  frequency,  preceding  the  shoulder  and  the  wrist.  Of  1883 
consecutive  cases  of  joint  disease  treated  at  the  Hospital  for 
Ruptured  and  Crippled  56  were  of  the  elbow. 

Pathology.  The  primary  disease  is  in  most  instances  osteal, 
as  in  92.8  per  cent,  of  the  cases  investigated  by  Scheimpflug,  44 
in  number.^  The  original  focus  of  infection  is  somewhat  more 
often  of  the  ulna  than  of  the  humerus.  Of  the  ulna  the  olecranon 
process,  and  of  the  humerus  the  external  condyle,  appear  to  be 
the  points  of  election.  Disease  of  the  head  of  the  radius  is  com- 
paratively infrequent.  In  119  cases  reported  by  Oilier  the 
olecranon  was  involved  in  73,  the  humerus  in  33,  and  the  radius 
in  12  instances.^  And  in  the  cases  investigated  by  Kummer,^ 
and  Middledorpt,*  the  ulna  was  more  often  the  seat  of  the  primary 
disease  than  was  the  humerus,  but  in  81  cases  treated  in  Koenig's 

1  Festschrift  fur  Billroth,  1892. 

2  Karewski.    Chir.  Krank.  des  Kindersalters,  p.  268. 

a  Deutsche  Zeits.  f.  Chir.,  Bd.  xxvii.  *  Archiv  f.  klin.  Chir.,  Bd.  xxxiii. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.     461 

clinic  the  primary  disease  was  of  the   humerus   in   43,    of  the 
olecranon  in  36,  and  of  the  radius  in  2  instances.^ 

Statistics. 

Age  at  Incipiency  of  Disease  at  the  Elbow-joint  in  Fifty-nine 
Consecutive  Cases  Treated  at  the  Hospital  for  Ruptured 
AND  Crippled. 


1  year  or  less  . 

.  2 

13  years  old 

.  3 

2  years  old 

.  5 

14     "     ... 

.  2 

3    "    .   .   . 

.  8 

15     "     ... 

4     "     .    .    . 

.  5 

17     "     ... 

5     "     .    . 

.  5 

19     "      ... 

6     "     .   .    . 

.  4 

21     "     ... 

7     '■     .    . 

.  8 

23     "      ... 

8     "     .    .    . 

.  1 

25     "     ... 

9     "     .    .    . 

.  2 

29     "     ... 

10     "     .    . 

.  5 

— 

11     "     .    . 

.  1 

Total 

.  59 

Males,  28 ;  females,  81 ;  right,  27  ;  left,  32. 

Symptoms.  The  symptoms  are  those  of  a  chronic,  persistent, 
destructive  disease.  Pain,  local  sensitiveness  and  swelling,  stiffness, 
deformity,  atrophy. 

The  pain  is  usually  localized  at  the  elbow.  It  is  increased  by 
sudden  movements,  and  as  the  bones  are  so  superficial  there  is 
usually  local  sensitiveness  to  pressure,  most  marked  over  the  seat 
of  the  disease.  In  the  early  stage  the  swelling  is  slight,  and  it 
is  of  the  peculiar  elastic  character  due  to  thickening  of  the  tissue 
rather  than  to  effusion  within  the  capsule,  but  as  the  disease 
progresses  the  joint  assumes  the  peculiar  spindle  shape  character- 
istic of  Avhite  swelling.  The  degree  of  elevation  of  the  local 
temperature  depends  upon  the  activity  of  the  disease.  The 
most  important  physical  sign  is  the  restriction  of  motion  due  to 
the  characteristic  muscular  spasm  which  becomes  evident  when 
the  limit  of  painless  motion  is  passed.  The  limitation  of  exten- 
sion and  flexion  gradually  increases,  and  finally  the  limb  becomes 
fixed  in  an  attitude  midway  between  flexion  and  extension,  with 
the  forearm  in  an  attitude  between  pronation  and  supination. 
This  is  the  characteristic  deformity  of  the  disease. 

Atrophy  of  the  muscles  of  the  arm  and  forearm  is  present, 
corresponding  to  the  intensity  and  duration  of  the  disease  and  to 
the  functional  disability  of  the  joint. 

Treatment.  The  treatment  here  as  elsewhere  consists  essen- 
tially in  placing  the  joint  at  rest  in  the  attitude  at  which  anchy- 
losis or  limitation  of  motion  will  least  inconvenience  the  patient, 

'  Koenig.    Lehrbuch  Spec.  Chir.,  Berlin,  1900. 


462 


ORTHOPEDIC  SURGERY. 


and  at  the  elbow-joint  this  is  practically  at  right  angular  flexion 
(Fig.  273). 

In  the  treatment  of  young  children  the  wrist  may  be  attached 
closely  to  the  neck  by  means  of  a  sling,  with  the  elbow  at  an 
acute  angle  (the  Thomas  method)  within  the  clothing.  Or  a 
light  plaster  bandage  may  be  used  to  fix  the  joint,  the  wrist  being 
supported  by  a  sling.  This  enables  the  patient  to  dress  himself 
without  moving  the  part,  and  it  protects  the  joint  from  injury. 
Other  forms  of  splints  may  be  employed,  but  the  plaster  bandage 

Fig.  272. 


Tuberculous  disease  of  the  elbow-joint. 


answers  every  purpose.  It  should,  of  course,  extend  from  the 
axilla  to  the  hand,  and  in  sensitive  cases  it  may  include  the  hand 
also. 

Reduction  of  Deformity.  In  many  instances  the  arm  is  fixed  in 
the  semi-extended  attitude  when  the  patient  is  brought  for  treat- 
ment. In  this  class  of  cases  a  simple  and  effective  means  of 
reducing  deformity  is  that  suggested  by  Thomas.  When  it  is 
impossible  to  bring  the  wrist  to  the  neck,  one  bends  the  neck 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.     463 

toward  the  wrist  and  attaches  the  two  by  a  bandage  that  the 
patient  is  unable  to  remove.  From  this  uncomfortable  attitude 
the  patient  can  free  himself  only  by  drawing  the  arm  toward  the 
neck  and  thus  reducing  the  deformity.  At  the  next  visit'the 
same  procedure  is  repeated,  until  finally  the  elbow  is  flexed  to 
the  required  degree.  A  permanent  sling  may  be  constructed  of 
a  leather  wrist-band  and  a  tube  of  leather  to  pass  about  the  neck, 
through  which  the  bandage  may  be  drawn  ;  thus  the  pressure  on 
the  wrist  and  neck  may  be  lessened.     In  the  very  resistant  cases 

Fig.  273. 


Tuberculous  disease  of  the  elbow-joint ;  the  stage  of  recovery. 


reduction  of  deformity  under  anaesthesia  may  be  required,  but 
this  is  not  often  necessary. 

Prognosis.  If  the  case  is  treated  at  an  early  stage  the  prog- 
nosis in  childhood  is  good.  The  duration  of  treatment  may  be 
estimated  at  two  years  or  more,  and  retention  of  a  fair  range  of 
motion  may  be  expected.  Anchylosis  in  the  right-angled  position 
does  not,  however,  seriously  inconvenience  the  patient,  provided 
the  cure  is  absolute.  The  loss  of  growth  is  usually  less  than 
when  the  upper  epiphysis  of  the  humerus  has  been  destroyed,  the 


464  ORTHOPEDIC  SURGERY. 

final  disproportion  depending,  of  course,  upon  the  age  of  the 
patient  and  upon  the  degree  of  function  that  is  preserved. 

Operative  Treatment.  In  some  instances  it  is  possible  to  re- 
move small  foci  of  disease  from  the  humerus,  or  from  the  ulna, 
before  the  joint  is  involved.  The  position  of  the  disease  may  be 
indicated  by  sensitiveness  or  swelling,  and  in  older  subjects  a 
Roentgen  picture  may  demonstrate  its  position  accurately. 

Excision  of  the  Elbow.  Excision  is  often  advisable  in  adolescent 
or  adult  life,  because  by  this  procedure,  in  most  instances,  the  dis- 
ease may  be  cured  in  a  definite  time  and  because  a  movable  joint 
may  be  assured. 

Oschman  has  recently  investigated  the  final  results  of  the 
operation  performed  on  this  class  at  Kocher's^  clinic  at  Berne, 
1872-1897.  In  40  of  45  cases  the  operation  was  performed  for 
tuberculous  disease.  There  were  no  deaths  referable  to  the 
operation.  Of  the  entire  number  of  cases  15  were  dead,  but  11 
of  these  survived  the  operation  for  from  five  to  twenty  years. 
Eight  of  the  deaths  were  due  to  tuberculosis,  2  to  other  causes, 
and  in  5  the  cause  of  death  was  unknown.  In  96  per  cent,  of 
the  cases  the  local  disease  was  cured.  In  68  per  cent,  of  the 
cases  the  patients  were  able  to  use  the  limb  at  hard  labor,  and  in 
the  others  it  was  efficient  for  light  work.  In  6  cases  there  was 
subluxation  or  luxation  ;  in  5  the  joint  was  not  firm.  In  59  per 
cent,  the  motions  were  practically  normal.  In  11  per  cent,  the 
joint  was  anchylosed. 

Tuberculous  Disease  of  the  Wrist-joint. 

Disease  of  the  wrist-joint  is  very  uncommon  in  childhood.  In 
a  total  of  3105  cases  of  tuberculous  disease  treated  in  the  out- 
patient department  of  the  Hospital  for  Ruptured  and  Crippled 
during  the  past  five  years,  98  were  of  the  upper  extremity,  and 
in  but  4  of  these  was  the  wrist-joint  involved.  Of  43  cases  in 
which  the  joint  was  resected  by  Oilier,  the  youngest  patient  was 
thirteen  years  of  age. 

Of  990  cases  of  disease  of  the  joints  in  childhood,  reported  by 
Karewski,  the  wrist  was  involved  in  31.^ 

Disease  of  the  wrist  in  older  subjects  is  less  infrequent,  although 
at  all  ages  it  is  rare  as  compared  with  disease  in  other  joints. 
Tuberculous  disease  of  the  metacarpus  and  phalanges  (spina 
ventosa)  is,  however,  far  more  common. 

1  Archiv  f.  klin.  Chir.,  1900,  Bd.  ]x.  H.  2. 

~  Chir.  Krank.  des  Kindersalters,  Berlin,  1894. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.     465 


Age  at  Incipiency  of  Disease  at  the  Wrist-joint  in  Eighteen 
Consecutive  Cases  Treated  at  the  Hospital  for  Euptured 
AND  Crippled. 


2  years  old 
6 


19  years  old 

20 

25 

26 

27 


Total 
Males,  11 ;  females,  7  ;  right,  12  ;  left,  6. 


Symptoms.  The  symptoms  of  tuberculous  disease  of  the  wrist 
are,  as  in  other  situations,  pain,  local  swelling  and  sensitiveness, 
limitation  of  motion,  caused  by  muscular  spasm,  and  atrophy.  In 
advanced  cases  the  hand  is  usually  flexed  somewhat  upon  the 
arm. 

Fig.  274. 


Tuberculous  disease  of  the  wrist  and  knee-joints,  showing  the  characteristic 
deformities  in  neglected  cases  of  a  severe  type. 


Treatment.  The  treatment  of  this,  as  of  other  joints,  is  func- 
tional rest,  with  support  in  the  attitude  in  which  anchylosis  or 
limitation  of  motion  will  cause  the  least  inconvenience.  A  light 
plaster  bandage  extending  from  the  elbow  to  the  tips  of  the 
fingers,  applied  over  a  flannel  bandage  drawn  as  tight  as  the  com- 
fort of  the  patient  will  permit,  is  a  satisfactory  support ;  or  a 
leather  splint  or  other  form  of  appliance  may  be  used.     The  hand 

30 


466 


ORTHOPEDIC  SURGERY. 


should  be  held  in  an  attitude  of  moderate  dorsal  flexion,  which 
will  permit  the  flexor  muscles  to  close  the  fingers  easily  if  the 
wrist  becomes  fixed  by  the  disease.  If  flexion  deformity  is 
present  it  should  be  corrected  by  degrees,  with  each  application 
of  the  bandage,  until  the  desired  attitude  is  attained  (Fig.  275). 
The  flannel  bandage  exercises  a  certain  amount  of  compression 
upon  the  wrist  which  seems  to  be  of  benefit,  and  in  certain 
instances  this  compression  and  fixation  may  be  still  further  in- 
creased by  the  application  of  adhesive  plaster.  When  the  disease 
of  the  joint  is  quiescent,  or  in  the  stage  of  recovery,  the  bandage 
or  splint  may  be  shortened  to  allow  the  patient  to  use  the  fingers. 
Prognosis.  The  prognosis  as  regards  function  in  cases  treated 
promptly  in  childhood  should  be  good.  In  the  adult  cases  wrist- 
joint  disease  seems  to  be  very  often  complicated  by  disease  of  the 
lungs ;  thus  the  prognosis  as  to  life  is  often  bad.  In  this  class 
of  cases  early  excision  is  usually  recommended,  with  amputation 
as  a  final  resort. 

Spina  Ventosa. 

Central  disease  of  the  long  bones  of  the  foot  and  hand  is 
the  most  common  form  of  diaphyseal  tuberculosis.     While  the 

Fio.  2". 


Treatment  of  tuberculosis  of  the  wrist-joint  by  plaster  of  Paris,  sho;ving  the 
proper  attitude. 


cortical  substance  is  destroyed  from  within  it  is  often  replaced 
in  part  by  a  formation  of  periosteal  bone  from  without,  which 
in  turn  may  be  destroyed  by  the  advancing  disease.  In  the 
early  cases  the  affected  bone  is  enlarged,  spindle-shaped,  and  is 
somewhat  sensitive  to  pressure.  At  this  stage  repair  may  take 
place  with  but  little  ultimate  change  from  the  normal,  but  in 
many  instances  the  bone  is  perforated  and  in  part  destroyed,  the 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.    467 

neighboring  joint  is  involved,  and  the  finger  becomes  stunted  and 
distorted. 

Fig.  276. 


^^^^^^^^^^^^^^H^HHpP^^ '^^ 

^^^^^■■■i 

■ 

f 

; 

^BHi^B^         . 

^jii..jA--i»<e'..^..-.M 

.  .-.M-^ 

i   mi 

ymm^, 

j| 

■kiiiH 

■■ 

K-^ 

Tuberculous  disease  of  the  carpus. 
Fig.  277. 


Tuberciiloiis  disease  of  tlie  left  wrist-joint.  The  irregularity  and  the  diminished  size  ot 
the  carpal  bones  indicate  the  extent  of  the  destructive  process.  The  patient,  the  mother  of 
the  child  (Figs.  10  and  11)  with  Pott's  disease,  died  within  a  year,  of  tuberculosis  of  the  lungs. 

In  159  cases  tabulated  by  Karewski/  the  metacarpal  bones 
were  diseased  in  65  instances  ;  the  phalanges  in  57  ;  the  meta- 
tarsal bones  in  29  ;  the  phalanges  of  the  toes  in  8.     In  a  number 

'  Chir.  Krank.  des  Kindersalters,  Berlin,  1894, 


468  ORTHOPEDIC  S UBGEB  Y. 

of  instances  several  of  the  bones  and  larger  joints  were  involved 
(159  cases  in  135  patients). 

The  disease  is  more  common  in  the  early  years  of  life,  84  of 
the  135  patients  being  four  years  of  age  or  less,  38  of  these 
being  less  than  two. 

Spina  ventosa  of  the  phalanges  may  be  treated  by  rest  and 
compression,  and  both  splinting  and  compression  may  be  exer- 
cised by  adhesive  plaster  strapping.  If  the  joint  is  involved 
amputation  of  the  finger  may  be  indicated,  because  of  the  dis- 
tortion and  loss  of  growth  that  may  be  expected.  Tuberculous 
disease,  limited  to  a  single  bone  of  the  carpus  or  metacarpus,  may 
be  treated  by  operative  removal  of  the  disease. 

Periarthritis  of  the  Shoulder. 

Under  the  title  of  scapulohumeral  periarthritis,  Duplay^  in 
1872  described  a  painful  affection  of  the  shoulder  induced  by 
traumatism,  dependent  upon  an  inflammation  of  the  bursa  lying 
between  the  deltoid  and  supraspinatus  and  infraspinatus  muscles 
and  the  coracoacromial  ligament.  But  under  this  title  are  now 
included  a  number  of  affections  that  cause  similar  symptoms  in 
which  it  would  appear  that  the  interior  of  the  joint  is  not  in- 
volved. 

Symptoms.  In  a  typical  case  of  so-called  periarthritis  the 
patient  complains  of  a  dull  pain  about  the  joint  and  sensitiveness 
to  pressure  just  below  the  acromion  process  or  over  the  bicipital 
groove.  The  pain  is  increased  by  motion,  particularly  by  abduc- 
tion or  by  rotation  of  the  arm.  In  mild  cases  only  extensive 
motion  causes  pain,  but  in  most  instances  there  is  a  constant  sen- 
sation of  discomfort  which  is  increased  to  acute  pain  by  sudden 
movements  or  jars.  The  part  becomes  sensitive  to  pressure,  so 
that  the  patient  avoids  lying  on  the  shoulder  at  night.  In  cer- 
tain instances  the  pain  may  radiate  down  the  arm,  and  there  may 
be  weakness  and  numbness  of  the  fingers.  Gradually  the  passive 
movements  of  the  joints  are  diminished  in  range,  and  atrophy  of 
the  shoulder  muscles  appears. 

These  symptoms  usually  pass  as  rheumatism,  but  there  is  no 
fever,  no  involvement  of  other  joints,  no  swelling,  and,  as  a  rule, 
no  general  sensitiveness  to  pressure,  as  is  usual  when  the  synovial 
membrane  of  the  joint  is  affected.  In  certain  instances  these 
symptoms  follow   injury,  or   exposure  to  cold,  or  they  appear 

1  Archiv.  g6n6rale  de  M(5d.,  Paris,  1872. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.     469 

without  apparent  cause.  In  one  class  of  cases  the  symptoms  may 
be  clue  to  an  inflammation  of  the  subdeltoid  bursa,  as  in  the  cases 
originally  described  by  Daplay  ;  in  others  to  a  tenosynovitis  of 
the  biceps  tendon  that  may  extend  to  the  surrounding  parts. 
This  is  suggested  by  local  sensitiveness  at  the  bicipital  groove, 
and  by  the  creaking  sensation  at  this  point  when  the  muscle  is 
in  use.  Ox  the  symptoms  may  be  due  to  neuritis  affecting  the 
circumflex  nerves,  as  suggested  by  Amidon.^  It  is  probable  also 
that  the  nerves  in  the  neighborhood  of  the  joint  may  be  second- 
arily implicated  in  an  inflammation  of  bursse,  or  directly  injured 
by  the  original  traumatism,  if  such  preceded  the  symptoms.  It 
is  also  possible  that  the  bursitis  may  have  been  a  sequel  of 
gonorrhoea  or  of  other  infectious  disease. 

Treatment.  During  the  acute  and  painful  stage  the  part 
should  be  kept  at  rest.  Cautery  may  be  applied  and  the  joint 
should  be  inclosed  in  adhesive  plaster  strapping,  and  if  the 
weight  of  the  limb  causes  discomfort  it  should  be  supported. 
In  certain  instances  tension  on  the  sensitive  part  may  be  relaxed 
by  supporting  the  arm  in  an  attitude  of  abduction.  When  the 
acute  symptoms  have  subsided  passive  movements,  massage,  and 
static  electricity  are  of  service.  Voluntary  exercises  should  be 
employed  when  they  no  longer  aggravate  the  symptoms.  In  the 
cases  of  long  standing  in  which  motion  is  very  much  restricted, 
apparently  by  adhesions  without  the  joint,  passive  movements 
under  anaesthesia  may  be  of  benefit.  In  such  cases  it  may  be 
well  to  support  the  limb  for  a  time  in  the  abducted  attitude  to 
prevent  the  formation  of  the  adhesions.  Afterward  passive 
motion,  massage,  and  exercises  may  be  employed.  If  these  cases 
are  treated  carefully  in  the  early  stage,  recovery  is  usually  rapid, 
but  if  neglected  the  symptoms  may  persist  indefinitely 

Chronic  Bursitis. 

Chronic  bursitis  at  the  shoulder-joint  is  comparatively  infre- 
quent. The  bursse  most  often  involved  are  the  coracoid,  i\\e 
subscapular,  and  the  deltoid.  Of  these  the  last  is  the  most  often 
affected.  Sixteen  cases  have  been  reported  by  Blauvelt,^  and 
three  others  by  Ehrhardt.^  The  enlarged  bursa  forms  a  fluctuat- 
ing swelling  most  evident  on  the  anterior  and  outer  aspect  of  the 
shoulder,  the  symptoms  being  discomfort,  weakness,  and  limita- 

'  American  Medico-Surgical  Bulletin,  March  21,  1896. 

'^  Beitriige  zur  klin.  Chir.,  lid.  x.xii.  ■'  Archiv  f.  klin.  Chir.,  1900,  Bd.  Ix. 


470  ORTHOPEDIC  SUROEBY. 

tion  of  motion  of  the  arm.  The  disease  is  usually  tuberculous  in 
character,  and  it  should  be  treated  by  incision  or  by  complete 
removal  of  the  sac  if  possible. 

Sprain  of  the  Wrist. 

This  is  a  very  common  accident.  The  most  effective  treatment 
is  the  adhesive  plaster  strapping  applied  about  the  metacarpus, 
wrist,  and  lower  half  of  the  forearm.  If  the  pain  on  motion  is 
severe  sufficient  plaster  is  applied  to  splint  the  part  and  to  limit 
movement  to  the  point  of  comfort.  If  the  injury  is  of  a  slighter 
grade  the  compression  and  support  of  a  single  layer  of  plaster 
is  usually  sufficient.  This  dressing  prevents  injury  and  yet  it 
allows  a  certain  degree  of  functional  use,  which  is  the  most  effec- 
tive means  of  restoring  a  joint  to  its  normal  condition  by  hasten- 
ing the  absorption  of  the  effused  material  within  and  without 
the  joint. 

Chronic  Sprain.  Persistent  weakness  and  stiffness  may  follow 
treatment  of  a  sprain  by  splints,  or  when  for  any  reason  disuse  of 
function  has  been  long  continued.  .  In  many  instances,  however, 
the  sprain  was  in  reality  a  fracture  or  displacement.  All  chronic 
sprains,  therefore,  should  be  examined  by  means  of  the  X-ray  in 
order  that  the  presence  or  absence  of  more  extensive  injury  may 
be  determined. 

The  treatment  is  similar  to  that  of  the  acute  sprain  :  protection 
from  injury,  and  functional  use  to  the  extent  of  which  the  part  is 
capable.  With  this,  massage,  hot  air,  and  electricity  or  other 
form  of  local  stimulation  may  be  employed  with  advantage. 
The  same  treatment  is  indicated  when  the  joint  is  stiff  and  painful 
as  the  result  of  rheumatism  or  other  inflammation,  provided  the 
stage  of  recovery  has  been  reached. 

Acute  Tenosynovitis. 

Tenosynovitis  is  common  at  the  wrist-joint.  It  is  usually 
induced  by  strain  or  overuse  of  a  muscle  or  muscular  group. 
Movements  of  the  muscles  that  are  involved  cause  discomfort, 
and  there  is  usually  local  sensitiveness  and  a  creaking  sensation 
on  palpation  over  the  affected  tendon  sheath.  The  adhesive 
plaster  strapping,  so  applied  as  to  exert  compression  and  to  pre- 
vent the  motion  that  causes  discomfort,  is  the  most  effective 
treatment. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY.     471 

Chronic  tenosynovitis,  causing  progressive  enlargement  of  a 
tendon  sheath  with  accompanying  symptoms  of  weakness  and 
discomfort,  is  usually  tuberculous  in  character.  In  such  cases 
the  diseased  part  should  be  promptly  removed.  If  the  disease  is 
of  long  standing,  extending  into  the  palm  of  the  hand,  it  may 
be  advisable  to  simply  evacuate  the  contents,  including  the  rice 
bodies,  through  an  incision.  An  astringent  solution  may  be 
injected,  and  after  its  removal  the  incision  may  be  closed. 
Pressure  is  then  applied,  with  the  aim  of  securing  partial 
adhesions  of  the  apposed  surfaces. 


CHAPTER   XIII. 

DEFORMITIES  OF  THE  UPPER  EXTREMITY. 

Congenital  Dislocation  of  the  Shoulder. 

This  may  occur  in  two  forms,  one  in  which  there  is  actual 
misplacement  before  birth,  and  the  other  in  which  a  dislocation 
is  caused  by  violence  at  birth.  In  either  case  the  displacement 
is  almost  always  backward  upon  the  dorsum  of  the  scapula 
(subspinous).  Thus  the  arm  is  abducted  and  rotated  inward, 
and  the  head  of  the  displaced  bone  may  be  felt  in  its  abnormal 
position.  Cases  of  congenital  displacement  in  other  directions 
are  recorded,  but  these  are  so  unusual  as  to  be  of  little  practical 
importance.^ 

True  primary  displacement  of  either  variety  is  uncommon. 
Many  of  the  reported  cases  were  apparently  subluxations  secondary 
to  the  relaxation  of  the  capsule  of  the  joint  and  to  the  muscular 
atrophy  caused  by  anterior  poliomyelitis,  or  more  often  to  the 
habitual  malposition  due  to  obstetrical  paralysis  (Fig.  278). 
According  to  Porter,^  twenty-nine  cases  are  recorded  in  literature, 
in  at  least  half  of  which  the  diagnosis  is  doubtful.  It  is,  of 
course,  apparent  that  both  displacement  and  paralysis  may  be 
coincident  and  caused  by  injury  at  birth. 

Treatment.  The  only  treatment  of  a  dislocation  is  replace- 
ment of  the  displaced  bone  if  it  be  possible.  If  the  displacement 
were  discovered  in  infancy  it  should  be  possible  to  reduce  it  by 
manipulation,  especially  if  it  were  of  traumatic  origin.  As  a 
rule,  however,  the  cases  are  not  seen  until  later  childhood,  when 
the  accommodative  changes  are  so  great  as  to  make  reposition 
difficult. 

Phelps,  of  Xew  York,  has  reported  several  cases  of  congenital 
dislocation  of  the  shoulder,  caused  apparently  by  injury  at  birth, 
as  most  of  them  were  accompanied  by  paralysis.  In  the  first 
case  (a  boy  eight  years  of  age)  the  joint  was  opened  by  a  posterior 
incision  along  the  border  of  the  deltoid  muscle.     The  head  of 

1  Scudder.    American  Journal  of  the  Medical  Sciences,  February,  1898. 

2  Transactions  of  the  American  Orthopedic  Association,  1900,  vol.  xiii. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY.  473 

the  scapula  was  found  to  be  atrophied,  and  the  posterior  margin 
of  the  glenoid  cavity  broken  away.  This,  together  with  the 
contraction  of  the  tissues  on  the  anterior  aspect  of  the  joint,  made 
it  necessary  to  cut  away  a  part  of  the  head  of  the  bone  in  order 
to  replace  it.  The  secondary  articulating  surface  on  the  scapula 
was  excised  and  the  redundant  capsule  was  removed.  The 
immediate  result  of  the  operation  was  very  favorable.  Phelps 
states  that  he  has  operated  on  two  similar  cases,  but  a  final  report 
of  the  results  has  not  been  presented.^  In  all  cases  of  this  char- 
acter limitation  of  motion  or  even  anchylosis  is  to  be  expected. 

It  would  seem,  however,  that,  as  in  a  posterior  displacement 
the  contracted  tissues  must  be  those  in  front  of  the  joint,  an 
anterior  rather  than  a  posterior  incision  would  be  preferable. 
In  any  event  prolonged  forcible  manual  stretching  of  the  con- 
tracted parts,  in  the  manner  described  in  the  treatment  of 
congenital  dislocation  of  the  hip  with  the  aim  of  securing  bloodless 
reposition,  should  precede  the  open  operation.  By  this  means  the 
writer  has  reduced  the  displacement  easily  in  several  cases  in 
early  childhood.  After  reduction  the  limb  should  be  fixed  for 
months  in  the  attitude  of  extension  on  the  scapula,  so  that  the 
head  of  the  humerus  may  be  forced  forward,  and  it  should  be 
rotated  outward  in  order  to  overcome  the  tendency  to  inward 
rotation  that  is  almost  always  present.  When  the  parts  have 
become  adapted  to  one  another  the  support  is  removed,  and 
manipulation  and  exercises  are  then  employed,  as  in  the  after- 
treatment  of  congenital  dislocation  of  the  hip.  If  the  bone 
cannot  be  retained  in  proper  position,  and  especially  in  those 
cases  in  which  the  paralysis  is  extensive,  the  joint  may  be  opened 
by  an  anterior  incision,  and  the  cartilage  may  be  removed 
from  the  humerus  and  scapula,  with  the  aim  of  obtaining  bony 
anchylosis.     (See  Arthrodesis.) 

Obstetrical  Paralysis. 

Partial  or  complete  paralysis  of  the  muscles  of  the  arm 
may  be  a  result  of  difficult  or  protracted  labor.  It  may  be 
caused  by  direct  injury  of  the  brachial  plexus,  but  most  often 
it  is  caused  by  traction  on  the  body  or  the  head,  and  by 
violent  twists  of  the  neck  during  delivery.  The  muscles  most 
often  paralyzed  are  those  supplied  principally  by  the  fifth  and 
sixth  cervical  roots  of  the  plexus,  the  deltoid,  the  biceps,  and  the 

1  Transactions  of  the  American  Orthopedic  Association,  vol.  viii. 


474 


ORTHOPEDIC  SURGERY. 


Fig.  278. 


supinators  of  the  forearm.^  Thus  in  most  instances  the  arm 
hangs  in  an  attitude  of  slight  abduction  and  exaggerated  prona- 
tion (Fig.  278).  If  the  attitude  is  allowed  to  persist  and  if  the 
paralysis  is  permanent,  the  head  of  the  humerus,  rotated  backward 
beneath  the  atrophied  deltoid  muscle  and  held  in  the  abnormal 

attitude  by  accommodative 
changes  in  the  capsule  and 
surrounding  parts,  simulates 
very  closely  in  later  years  the 
true  congenital  dislocation  of 
the  shoulder  (Fig.  279). 

Whether  cases  reported  as 
congenital  displacement  of 
the  shoulder  are  secondary  to 
paralysis  or  not,  it  is  evident 
that  all  cases  of  obstetrical 
paralysis  should  be  carefully 
examined  with  regard  to  a 
complicating  dislocation,  and 
that  the  secondary  deformity 
induced  by  paralysis  should 
be  prevented. 

Treatment.  During  the 
first  month  after  birth  the 
shoulder  of  the  paralyzed  arm 
is  often  somewhat  swollen, 
and  motion  may  cause  pain. 
In  such  cases  rest  is  in- 
dicated. The  arm  should 
be  placed  against  the  side,  and  the  hand,  with  the  fingers 
extended,  should  be  supported  on  the  chest  beneath  the  clothing. 
When  the  primary  sensitiveness  has  subsided,  each  of  the  joints 
of  the  extremity  should  be  moved  systematically  to  the  limits  of 
the  normal  range  of  motion  several  times  in  a  day.  Particular 
care  should  be  exercised  in  supinating  the  forearm  and  ex- 
tending the  wrist  and  fingers,  if  they  are  involved  in  the 
paralysis.  The  muscles  should  be  massaged,  and  the  arm  should 
be  supported  by  a  sling,  or  otherwise,  in  proper  position. 
Recovery  may  be  complete,  although  it  is  often  delayed  for 
many  months.     As  a  rule,  traces  of  the  injury  are  evident  in 


Obstetrical  paralysis.    Characteristic  attitude. 


1  Thomas.    Johns  Hopkins  Hospital  Bulletin,  November,  1900. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY. 


475 


atrophy  of  certain  muscles,  particularly  of  the  deltoid,  and  a 
certain  weakness  of  the  arm  persists,  even  though  no  paralysis 
remains. 

In  many  instances  recovery  is  but  partial,  the  arm  is  weak, 
certain  muscles  are  paralyzed,  and  there  is  much  restriction  of 
movement  at  the  shoulder.  The  growth  of  the  member  is  re- 
tarded, and  the  attitude  simulates  that  of  posterior  dislocation,  as 

Fig.  279. 


Obstetrical  paralysis  in  adolescence. 


has  been  stated.  Even  in  such  cases  massage,  exercises  and 
training  will  often  improve  the  functional  ability  of  the  disabled 
part.  If  from  neglect  of  treatment  subluxation  of  the  humerus 
is  present,  it  should  be  reduced  by  manipulation  in  the  manner 
described.  In  certain  cases  of  this  character  function  may  be 
greatly  improved,  if  the  operation  is  supplemented  by  massage 
and  appropriate  training. 


476  ORTHOPEDIC  S  UB GEB  Y. 

Recurrent  Dislocation  of  the  Shoulder. 

Recurrent  dislocation  of  the  shoulder  is  in  most  instances  a 
sequel  to  traumatic  dislocation.  The  cause  of  the  instability  is 
usually  laxity  of  the  capsular  ligament  and  weakness  of  the  sup- 
porting muscles,  the  result,  it  may  be,  of  too  early  use  of  the 
arm  after  the  accident.  In  rare  instances  greater  derangement 
of  the  joint,  caused  by  fracture  of  one  or  other  of  the  articulating 
surfaces,  rupture  or  displacement  of  ligaments  or  muscles,  or 
permanent  paralysis  of  the  deltoid  muscle,  may  be  present. 

The  displacement,  which  may  be  partial  or  complete,  recurs  at 
intervals  and  is  a  very  serious  disability. 

Treatment.  If  the  patient  is  seen  immediately  after  a  dis- 
placement and  if  the  dislocation  has  recurred  but  a  few  times  and 
at  long  intervals,  it  may  be  inferred  that  the  disability  is  the 
result  of  simple  laxity  of  the  capsule  and  of  muscular  weakness. 
In  such  cases  a  period  of  fixation  followed  by  massage  and  exer- 
cise of  the  atrophied  muscles  may  result  in  cure.  The  patient 
should  be  carefully  questioned  as  to  the  particular  movements  of 
the  arm  that  are  likely  to  cause  the  displacement,  which  is,  as  a 
rule,  forward  beneath  the  coracoid  process.  Most  often  elevation 
and  abduction  seem  to  be  the  predisposing  movements  that 
should  be  restrained.  A  simple  and  often  an  effective  means  of 
treatment  is  the  application  of  a  shoulder  cap  of  canvas  that  fits 
closely  about  the  shoulder  and  upper  arm.  This  is  held  in  place 
by  bands  crossing  the  body  and  buckled  beneath  the  other  arm  ; 
from  the  lower  border  of  the  cap  one  or  more  bands  pass  down- 
ward and  are  attached  with  the  braces  to  the  trousers,  so  that 
elevation  of  the  arm  is  restrained,  before  the  point  of  instability 
is  reached. 

Operative  Treatment.  If  these  milder  measures  are  ineffective, 
an  operation  to  reduce  the  size  of  the  lax  capsule  may  be  per- 
formed according  to  the  method  employed  by  Burrell.  The  arm 
being  slightly  abducted,  an  incision  is  made  from  the  coracoid 
process  downward  and  outward  along  the  line  of  the  cephalic 
vein  to  a  point  below  the  upper  border  of  the  tendinous  insertion 
of  the  pectoralis  major.  The  deltoid  and  the  pectoralis  major 
are  separated,  exposing  in  the  upper  border  of  the  wound  the 
coracobrachialis,  and  in  the  lower  angle  the  upper  part  of  the 
insertion  of  the  pectoralis  major  muscles.  The  upper  three- 
fourths  of  this  insertion  is  divided  in  order  to  expose  the  head 
and  neck  of  the  bone.     The  humerus  is  then  rotated  outward 


DEFORMITIES  OF  THE  UPPER  EXTREMITY.  477 

and  a  portion  of  the  insertion  of  the  subscapularis  muscle, 
stretched  over  the  head  of  the  humerus,  is  divided.  The  capsule 
is  thus  laid  bare. 

In  Burrell's  second  case  a  portion  of  the  anterior  wall  of  the 
capsule  three-eighths  of  an  inch  wide  and  three-fourths  of  an 
inch  long  was  excised,  and  the  wound  was  closed  with  sutures. 
The  incised  muscles  fell  into  apposition  when  the  arm  was  fixed 
to  the  side.  Burrell  has  operated  on  two  patients  by  this  method 
with  perfect  success. 

Similar  operations  in  which  the  lax  capsule  was  overlapped 
and  sutured  without  opening  it  have  been  performed,  by  Ricard 
in  1892  and  by  Steinthal  in  1895.^ 

Cong-enital  Deformities  of  the  Elbow. 

Congenital  displacement  of  the  ulna  is  one  of  the  rarest  of 
deformities.  The  displacement  is  usually  incomplete,  and  it  is 
associated  with  laxity  of  the  ligaments. 

Congenital  displacement  of  the  radius  is  much  more  common. 
Thirty  cases  collected  from  the  literature  have  been  reported  by 
Bonnenburg.^  The  symptoms  are  similar  to  those  of  traumatic 
dislocation.  The  deformity  is  often  overlooked  in  childhood,  and 
as  it  causes  no  great  disability,  treatment  is  not  usually  desired.  In 
several  instances  the  head  of  the  radius  has  been  removed  with  a 
favorable  effect  in  increasing  the  range  of  supination. 

Cubitus  Valgus,  Cubitus  Varus. 

Cubitus  valgus,  in  which  the  forearm  is  abducted  at  the  elbow, 
and  cubitus  varus,  in  which  it  is  inclined  in  the  other  direction, 
are  occasionally  seen  as  congenital  deformities.  They  are,  in 
most  instances,  associated  with  laxity  of  the  ligaments. 

Similar  deformities  are  not  uncommon  during  the  progressive 
stage  of  rhachitis,  but  they  usually  disappear  when  the  erect 
attitude  is  assumed  and  when  the  arms  are  relieved  of  the  strain 
of  supporting  the  body  in  the  sitting  posture. 

The  forearm  forms  an  angle  with  the  upper  arm,  opening 
outward  when  the  limb  is  extended  at  about  173  degrees  in 
males  and  1G7  degrees  in  females.^  This  is  sometimes  called 
the  "  carrying  "  angle,  because  the  hand  is  held  at  some  distance 

1  Burrell  and  Lovett.    American  Journal  of  the  Medical  Sciences,  August,  1897. 

2  Zeits.  f.  Orth.  Chir.,  Bd.  ii. 

"  Potter.    .lonrrial  of  Anatomy  and  Physiology,  vol.  xxix,  p.  488, 


478  ORTHOPEDIC  S  UJR GEB  Y. 

from  the  body  while  the  arm  is  in  contact  with  the  trunk.  What 
may  be  called  normal  cubitus  valgus  is  common  among  women, 
and  in  certain  instances  it  may  be  exaggerated  to  deformity. 
Acquired  cubitus  varus  is  usually  the  result  of  direct  injury. 
Both  deformities  may  be  treated  by  osteotomy  of  the  humerus 
just  above  the  articulation  after  the  method  used  to  correct 
similar  deformity  at  the  knee. 

Subluxation  of  the  Wrist. 

A  peculiar  displacement  of  the  hand  forward  and  usually  toward 
the  radial  side,  described  by  Madelung^  as  "  spontaneous  subluxa- 
tion," is  sometimes  seen  in  young  subjects  whose  occupation  may 
require  constant  use  of  the  flexors  of  tlie  hand  and  fingers.  In 
these  cases  the  lower  extremity  of  the  ulnar  is  displaced  toward 

Fig.  280. 


Spontaneous  subluxation  of  the  wrist. 

the  dorsum  of  the  hand  ;  there  is  abnormal  separation  of  the  two 
bones  of  the  forearm  from  one  another  at  the  wrist,  and  in  many 
instances  the  lower  extremity  of  the  radius  is  bent  forward.  As 
a  consequence  the  wrist  is  enlarged,  the  ligaments  are  relaxed, 
and  dorsal  flexion  of  the  hand  is  restricted.  The  symptoms, 
aside  from  the  deformity,  are  weakness  and  sensations  of  discom- 
fort about  the  dorsum  of  the  wrist. 

Etiology.  The  predisposing  causes  of  the  affection  are, 
apparently,  relaxation  of  the  ligaments,  and,  possibly,  slight 
pre-existing  rhachitic  deformity  of  the  same  character.  The 
exciting  causes  are  occupation  or  injury.  The  slight  forward 
bending  of  the  lower  extremity  of  the  radius  is  due,  apparently, 
to  irregularity  in  growth  at  the  epiphyseal  junction. 

1  Archiv  f.  klin.  Chir.,  Bd.  xxiii. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY.  479 

Treatment.  The  treatment  is  rest,  massage,  forcible  manipu- 
lation in  the  direction  of  extension,  and  a  support  of  .leather  or 
other  material  to  hold  the  hand  in  the  extended  position.  In 
more  extreme  cases  the  deformity  of  the  radius  may  be  overcome 
by  osteotomy. 

Congenital  Deformities  at  the  Wrist. 

Simple  congenital  dislocation  of  the  wrist  is  extremely  rare. 
Displacement  of  the  wrist  and  hand  is  usually  associated  with 
defective  development  of  the  bones  of  the  arm,  and  the  deformity 
is  usually  classed  as  club-hand. 

Club-hand. 

Congenital  distortions  of  the  hand  may  be  divided  into  four 
primary  varieties,  according  to  the  direction  in  which  the  hand  is 
turned,  viz. : 

1.  Forward  or  palmar. 

2.  Backward  or  dorsal. 

3.  Lateral  to  the  radial  side — radial. 

4.  Lateral  to  the  ulnar  side — ulnar. 

Lateral  and  anteroposterior  distortions  occur  also  in  combina- 
tion. 

Etiology.     There  are  two  distinct  varieties  of  club-hand  : 

1.  In  which  there  is  simple  distortion  caused  apparently  by 
abnormal  restraint  and  pressure  in  utero.  In  certain  cases  of 
this  class  there  may  be  limited  motion  at  both  the  shoulder-joint 
and  elbow-joint  and  defective  muscular  development  apparently 
dependent  upon  long-continued  fixation. 

2.  In  which  the  deformity  is  associated  with  defective  develop- 
ment of  the  radius  or  ulna  and  often  with  congenital  abnormali- 
ties of  other  parts. 

In  the  palmar  and  dorsal  distortions  the  bones  of  the  arm  are 
usually  normal.  The  lateral  deviations  of  the  hand  are  often 
complicated  by  defective  formation  of  the  radius  or  ulna,  and 
thus  they  correspond  to  talipes  due  to  absence  of  the  tibia  or 
fibula. 

According  to  Hoffa,^  39  cases  of  the  former  and  but  6  of  the 
latter  are  recorded  ;  in  but  1  case  was  there  entire  absence  of  the 
ulna.     Of  the  39  cases  of  radial  club-hand  19  were  of  both  sides. 

1  Lehrb.  der  Orth.  Chir.,  p.  481. 


480 


ORTHOPEDIC  SURGERY. 


These  statistics,  however,  by  no  means  represent  the  relative  fre- 
quency of  the  deformity.  From  the  writer's  observation  it 
would  appear  that  radial  club-hand  is  nearly  as  common  as  the 
deformity  of  the  foot  caused  by  absence  of  the  fibula,  of  which, 
according  to  Potel,  there  are  200  recorded  cases.  The  ulnar 
form  of  club-hand  is  less  frequent  even  than  the  deformity  due 
to  defective  formation  of  the  tibia. 

The  most  important  form  of  club-hand  is,  then,  that  due  to 
absence  or  to  defective  formation  of  the  radius.  As  in  talipes 
valgus  due  to  absence  of  the  fibula,  the  tibia  is  short  and  often 

Fig.  281. 


Club  hands  and  club-feet. 


bent  sharply  forward,  so  in  this  form  of  club-hand  the  ulna  is 
usually  short  and  bent  inward.  The  hand  may  be  perfect  in 
formation,  but,  as  a  rule,  the  thumb  is  absent  or  rudimentary, 
and  other  adjoining  bones,  together  with  the  corresponding  liga- 
ments and  muscles,  may  be  absent  also  (Fig.  282). 

The  hand  occupies  practically  a  right-angled  relation  to  the 
ulna,  and  as  this  bone  is  usually  bent  inward  as  well  the  direction 
of  the  hand  is  often  reversed  and  is  parallel  to  the  forearm.  As 
a  rule,  the  hand  is  also  somewhat  bent  forward,  so  that  the 
deformity  might  be  described  as  radiopalmar  (Fig.  283). 


DEFORMITIES  OF  THE  UPPER  EXTREMITY. 


481 


Treatment.  In  those  forms  o£  club-hand  in  which  the  struc- 
ture is  normal  the  deformity  may  be  overcome,  as  a  rule,  by 
manipulation,  and  support  by  the  plaster  bandage  or  otherwise, 
as  described  in  the  treatment  of  talipes.  Massage  and  muscle 
training  are  required  in  the  after-treatment.  If  the  deformity  is 
complicated  by  defective  muscular  development  and  limited  joint 
motion  massage  and  passive  manipulation  may  be  required  for 
years.     Complete  recovery  is  unusual. 

In  slighter  cases  of  radial  club-hand,  due  to  defective  develop- 
ment, it  may  be  possible  by  manipulation  and  tenotomy  to  replace 

Fig.  282. 


Congenital  absence  of  radius  and  the  bones  of  the  thumb.    (Weigel.) 

the  hand  in  its  normal  position,  but  this  is  unusual.  As  a  rule, 
an  operation  on  the  ulna  will  be  necessary,  together  with 
division  of  the  contracted  tissues.  Sayre^  removed  a  portion  of 
the  carpus  and  implanted  the  head  of  the  ulna  at  the  point  of 
resection.  McCurdy^  sawed  through  the  ulna,  leaving  the 
extremity  in  relation  to  the  carpus  and  sutured  the  proximal 
fragment  and  the  semilunar  bone  to  one  another.  Thomson^ 
replaced  the  hand  by  subcutaneous  tenotomy  and  by  the  removal 
of  a  cuneiform  section  of  bone  from  the  lower  end  of  the  ulna. 


'  Transactions  of  the  American  Orthopedic  Aspociation,  vol.  vi. 
'^  Ibid.,  vol.  viii.  a  ibid.,  vol.  ix. 

31 


482 


OB THOPEDIC  SUROEB Y. 


Fig.  283. 


The  operation  of  splitting  the  ulna  into  an  ulnar  and  radial 
portion  and  implanting  the  carpus  between  the  two  has  been 
performed  by  Bardenhauer.^     The  immediate  effect  of  the  various 

operative  procedures  was  favor- 
able, but  no  final  results  have 
been  reported. 

In  any  event  some  form  of 
apparatus  must  be  used  during 
childhood  at  least,  to  support 
the  hand,  whether  the  operation 
has  been  successful  or  not ;  and 
at  best  the  arm  will  be  short 
and  the  thumbless  hand  weak 
as  compared  with  its  fellow. 

Congenital  Contraction  of 
the  Fingers. 

The  most  common  form  of 
congenital  contraction  is  that  of 
the  little  finger  (hammer  finger) 
of  one  or  both  hands.  This  is 
semiflexed  and  extension  is 
checked  by  what  appears  to  be 
a  congenital  shortening  of  all 
the  soft  parts  on  the  flexor 
side.  In  other  instances  several 
fingers  may  be  similarly  af- 
fected. 

Treatment.    If  treatment  by 
congenital  club-hands,  showing  the  short    manipulation  and   Splinting  is 

and  deformed  forearms,  also  bow-legs.    (Gib-     Kpo-un  Carlv  the  deformity  may 

be  overcome  by  lengthening 
the  contracted  tissues.  In  later  life  the  prospect  of  perfect  cure 
by  any  method  of  treatment  is  slight,  because  of  the  strong  ten- 
dency to  recontraction  after  the  finger  has  been  straightened. 

Webbed  Fingers. 

In  the  most  common  form  of  this  deformity  two  or  more 
fingers  are  joined  by  skin  and  fibrous  tissue  to  the  first  phalangeal 
joints,  but  sometimes  throughout  the  entire  length  of  the  fingers. 

1  Verhand.  der  deutsch.  Gesells.  f.  Chir.,  23  Kong.,  1894. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY.  483 

In  other  instances  the  web  may  be  thicker,  containing  muscular 
fibres  from  the  apposed  parts,  and,  occasionally,  the  bones  of  the 
two  fingers  may  be  joined  to  one  another,  even  to  the  finger-nails. 

Etiology.  The  cause  of  the  deformity  is  arrest  of  develop- 
ment before  the  fingers  have  been  separated  from  one  another ; 
thus  the  thumb,  which  is  differentiated  from  the  other  parts  of 
the  hand  as  early  as  the  seventy-fifth  day  of  intra-uterine  life,  is 
rarely  involved,  as  compared  with  the  fingers,  which  are  separated 
from  one  another  at  a  later  period. 

Treatment.  In  all  but  the  extreme  grades  of  deformity  the 
fingers  may  be  separated  from  one  another  ;  operative  treatment 
being  conducted  according  to  the  rules  of  plastic  surgery. 

Congenital  Displacements  of  the  Phalanges  and  Distortions 
of  the  Fingers. 

These  deformities  are  not  particularly  uncommon.  They 
should  be  treated  by  manipulation  and  by  splinting  at  as  early 
a  period  as  is  practicable.  Other  congenital  deformities  and 
malformations  of  the  hand  do  not  call  for  extended  comment. 

Trigger  Finger. 

Synonyms.      Jerking  finger,  snapping  finger. 

This  affection  was  first  described  by  Nelaton  under  the  title 
"  Doigt  a  Ressort."  On  extending  the  closed  hand  one  finger 
remains  flexed.  If  the  flexion  is  overcome  by  greater  muscular 
effort  or  by  passive  force  the  finger  flies  back  to  complete  exten- 
sion with  a  sudden  snap  or  jerk  ;  hence  the  name.  In  well- 
marked  cases  the  same  difiiculty  and  the  subsequent  snap  is 
experienced  in  flexing  the  finger.  The  middle  and  ring  fingers 
are  more  often  affected,  but  sometimes  the  thumb  or  the  fifth 
finger  may  be  involved. 

The  patient  usually  complains  somewhat  of  stiffness  and  pain 
in  the  finger,  but  the  interference  with  its  function  is  the  prin- 
cipal symptom. 

Etiology.  The  usual  explanation  of  the  disability  is  inter- 
ference with  the  motion  of  the  tendon  in  its  fibrous  sheath,  either 
because  of  a  reduction  of  its  calibre  due  to  injury  or  inflammation, 
or  to  an  enlargement  or  irregularity  of  the  tendon  itself.  In 
most  instances  the  obstruction  appears  to  be  in  the  neighborhood 
of  the  metatarsophalangeal  joint. 

The  duration  of  the  affection  is  indefinite. 


484  ORTHOPEDIC  S UB GER  Y. 

Treatment.  If  the  obstruction  appears  to  be  of  inflammatory 
or  traumatic  origin  it  may  be  treated  by  splinting  and  later  by 
massage.  In  confirmed  cases  the  tendon  and  the  sheath  may  be 
explored  in  the  hope  of  finding  and  removing  the  obstruction.^ 

Mallet  Finger. 

Synonym.     Drop-finger. 

This  is  caused  usually  by  a  blow  upon  the  terminal  phalanx, 
which  ruptures  or  weakens  the  attachment  of  the  extensor  tendon 
at  the  base  of  the  phalanx  so  that  it  is  habitually  flexed  some- 
times nearly  to  a  right  angle. 

The  treatment  must  be  by  incision  and  reattachment  of  the 
tendon  to  the  periosteum. 

"Baseball  finger  "  is  the  reverse  displacement  of  the  terminal 
phalanx  which  is  dislocated  backward,  forming  a  bayonet-like 
deformity.  There  is  often,  in  addition,  injury  of  the  base  of  the 
phalanx  that  causes  subsequent  irregular  hypertrophy. 

If  reposition  is  impossible  open  incision  may  be  employed  to 
correct  the  deformity. 

Dupuytren's  Contraction. 

Dupuytren's  contraction  is  a  deformity  of  the  hand  caused  by 
contraction  of  a  part  of  the  palmar  fascia  and  of  its  prolongations 
to  one  or  more  of  the  fingers.  The  fingers  are  flexed  as  a  conse- 
quence to  a  greater  or  less  degree,  and  in  advanced  cases  they 
may  be  drawn  to  close  contact  with  the  palm.  The  ring  finger 
is  most  often  primarily  affected,  but,  as  a  rule,  two  or  more 
fingers  are  somewhat  involved  in  the  contraction. 

In  a  large  proportion  of  the  cases  both  hands  are  affected, 
but  not  as  a  rule  simultaneously,  the  contraction  beginning  in  the 
second  hand  several  years  after  the  deformity  in  the  first. 

Pathology.  The  characteristics  of  the  deformity  are  explained 
by  the  anatomy  of  the  palmar  fascia.  This  consists  of  a  strong 
central  portion,  and  two  thinner  lateral  parts  that  cover  the 
muscles  of  the  thumb  and  little  finger.  It  is  made  up  of  longi- 
tudinal fibres  continuous  with  the  tendon  of  the  palmaris  longus, 
and  the  annular  ligament.  It  divides  into  four  processes  that 
are  attached  to  the  digital  sheaths,  to  the  integument  at  the  clefts 
of  the  fingers,  and   to  the  superficial  transverse  ligament.     Pro- 

1  The  bibliography  is  large.    More  recent  articles  are  those  of  Jamiu,  Cent.  f.  Chir.,  June 
6,  1896,  who  reports  thirty-one  cases,  and  A.  Necker,  Beitrage  zur  klin.  Chir.,  B.  x.  p.  469. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY.  485 

longations  of  the  fascia  pass  along  the  lateral  aspect  of  the  fingers 
and  are  attached  to  the  periosteum  and  to  the  tendon  sheaths  of 
the  first  and  second  phalanges. 

The  cause  of  the  contraction  appears  to  be  a  chronic  plastic 
inflammation  of  a  part  of  the  fascia,  which  becomes  hypertrophied 
and  finally  contracts,  drawing  the  finger  toward  the  palm  in  the 
manner  described. 

Etiology.     The  etiology  is  uncertain. 

The  contraction  is  much  more  common  in  men  than  in  women, 
and  it  is  practically  confined  to  middle  and  later  life.  It  is 
claimed  that  the  deformity  is  more  common  among  those  who 
are  subject  to  gout  or  rheumatism.  It  appears,  also,  to  be  an 
hereditary  affection  in  certain  instances.  Injury  or  irritation  of 
the  palmar  tissues,  incident  to  certain  occupations,  would  seem 
to  explain  the  disproportionate  liability  of  the  sexes  to  the 
affection. 

Symptoms.  The  first  symptom  is  usually  the  deformity  ;  the 
patient  finds  it  impossible  to  completely  extend  one  or  more  of 
the  fingers ;  the  tissues  about  the  base  of  the  finger  seem  stiff, 
and  when  it  is  forcibly  extended  a  hard,  elevated  cord  may  be 
felt  extending  from  about  the  centre  of  the  palm  to  the  second 
phalanx,  most  prominent  at  the  metacarpophalangeal  articulation. 

To  this  the  skin  is  adherent,  and  as  the  contraction  increases 
it  is  thrown  into  elevated  ridges.  Later  other  bands  appear  if 
the  contraction  affects,  as  it  usually  does,  other  portions  of  the 
fascia.  In  many  instances  no  paia  is  experienced  unless  the 
contracted  fascia  is  forcibly  stretched  or  is  pressed  upon.  In 
other  cases  complaint  is  made  of  neuralgic  pain  in  the  hand  and 
even  in  the  arm  and  back.  Occasionally  the  first  symptom  to 
attract  attention  may  be  a  sensitive  nodule  in  the  skin  at  the 
base  of  the  finger. 

The  contraction  usually  increases  slowly  until  the  finger  that 
is  most  affected  is  drawn  to  the  palm. 

Treatment.  The  deformity  may  be  overcome  in  part  by 
multiple  division  of  the  contracted  bands  from  the  finger  to  the 
palm,  but  complete  removal  of  the  contracted  fascia  is  preferable 
if  it  be  possible.  The  finger  is  then  supported  in  an  attitude 
of  slight  flexion  until  the  circulation  is  adjusted  to  the  new 
position. 


CHAPTER    XIY. 

CONGENITAL    AND    ACQUIRED     AFFECTIONS    LEADING    TO 
GENERAL  DISTORTIONS. 

Rhachitis. 

Synonym.     Rickets. 

Rhachitis  is  a  constitutional  disease  of  infancy  caused  by 
defective  nutrition,  of  which  the  most  marked  effect  is  distortion 
of  the  bones. 

Etiology.  The  predisposing  cause  is  constitutional  weakness. 
This  may  be  inherited  or  it  may  be  the  direct  effect  of  illness, 
but  most  often  it  is  the  result  of  improper  hygienic  surroundings, 
particularly  lack  of  sunlight,  damp  rooms,  overcrowding,  and 
defective  ventilation.  The  direct  cause  of  the  disease  is  im- 
proper nourishment.  In  most  instances  this  is  due  to  the  substi- 
tution of  artificial  food  for  the  mother's  milk,  in  others  to 
improper  diet  after  the  infant  is  weaned  ;  in  rare  cases  it  may  be 
the  result  of  prolonged  lactation,  or  it  may  be  caused  by  the 
defective  quality  of  the  mother's  milk.  The  disease,  therefore, 
begins  usually  between  the  ages  of  six  and  eighteen  months, 
although  it  is  by  no  means  confined  to  these  limits.  In  most 
instances  improper  surroundings  and  improper  nourishment  are 
combined  in  the  causation  of  the  disease  ;  thus  rhachitis  is  rela- 
tively common  in  large  cities.  At  the  Hospital  for  Ruptured 
and  Crippled  the  most  extreme  cases  are  observed  among  the 
Italian  and  the  colored  children.  The  former  are  usually  nursed, 
but  are  improperly  fed  after  weaning,  while  the  latter,  if  nursed 
at  all,  are  usually  allowed  a  mixed  diet  even  during  the  early 
months  of  life. 

Pathology.  The  manifestations  of  a  disease  dependent  upon 
impaired  nutrition  are,  of  course,  general  in  character.  In 
rhachitis  there  is  a  mild  degree  of  anaemia,  and  a  general  weak- 
ness and  relaxation  of  the  voluntary  and  involuntary  muscles. 
As  a  result  the  circulation  is  impaired  and  the  power  of  assimila- 
tion is  diminished;  thus  congestion  and  enlargement  of  the 
internal  organs,  intestinal  catarrh,  bronchitis,  and  the  like  are 
common  accompaniments  of  the  disease.  The  most  marked  and 
characteristic  changes  are  found  in  the  bones  ;  these  consist  in 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     487 

a  diminution  of  the  earthy  substances  and  in  overgrowth  of 
osteoid  tissue. 

"  The  essential  features  of  the  morbid  processes  are,  first,  an 
exaggeration  of  the  processes  immediately  preparatory  to  the 
development  of  true  bone  ;  secondly,  an  imperfect  conversion  of 
this  preparatory  tissue  into  true  bone  ;  and,  thirdly,  a  great 
irregularity  of  the  whole  process."     (Erichsen.) 

On  section  of  rhachitic  bone  it  will  be  noted  that  the  perios- 
teum is  increased  in  thickness,  and  is  more  or  less  adherent  to 
the  underlying  softened  and  spongy  tissue.  The  medullary  canal 
is  enlarged,  and  its  contents  are  abnormally  vascular.  The 
epiphyseal  cartilage,  normally  a  thin,  bluish  line,  is  much  increased 
in  thickness.  It  appears  to  be  swollen  and  infiltrated,  and  it  has 
lost  its  former  translucency.  Microscopic  examination  at  this 
point,  where  growth  is  most  active,  shows  marked  irregularity 
in  size  and  shape  of  the  columns  of  cartilage  cells  ;  the  zone  of 
calcification  is  lacking  or  is  ill-defined,  and  masses  of  cartilage 
cells  are  found  unchanged  in  what  should  be  the  area  of  true 
bone.  The  same  irregularity  of  line  and  shape  is  observed  in 
the  medullary  spaces  of  the  newly-formed  osteoid  tissue. 

As  a  direct  result  of  the  changes  that  have  been  described,  the 
epiphyseal  junctions  are  enlarged  and  the  shafts  of  the  bones  are 
thickened  by  the  formation  of  osteoid  tissue  beneath  the  perios- 
teum. The  indirect  effects  of  the  disease,  and  of  the  weakness 
that  it  causes,  are  deformities,  the  nature  of  which  will  be  indi- 
cated under  the  heading  of  symptoms.  The  stage  of  weakness 
is  followed  by  that  of  repair,  which  sometimes  goes  on  with 
great  rapidity  ;  the  softened  bones  become  abnormally  hard, 
"  eburnated,"  and  premature  solidification  at  the  epiphyseal 
junctions  may  be  one  of  the  remote  results  of  the  disease  that 
accounts  in  part  for  the  dwarfing  of  the  stature,  observed  as  one 
of  the  final  results  of  severe  rhachitis. 

Symptoms.  As  the  disease  is  the  effect  of  imperfect  assimila- 
tion its  more  pronounced  symptoms  are  preceded  by  those  of 
indigestion,  such  as  flatulence,  constipation,  and  the  like.  Pro- 
fuse perspiration,  especially  about  the  head,  and  restlessness  at 
night  are  common  symptoms.  Teething  is  often  delayed  or  is 
irregular.  The  infant  is  slow  in  its  movements,  and  makes  little 
effort  to  stand  or  to  walk  at  the  usual  time,  and  if  the  disease  is 
active  the  affected  parts  may  be  sensitive  to  pressure. 

Deformities.  The  deformities  are  in  part  due  to  the  direct  effect 
of  the  disease.     One  of  the  earliest  and  most  constant  evidences 


488  ORTHOPEDIC  SURGERY. 

of  rhachitis  is  the  enlargement  about  the  epiphyses,  an  enlarge- 
ment caused  in  part  by  the  direct  hypertrophy  and  in  part  by 
pressure  upon  the  softened  tissues.  The  enlargements  at  the 
junctions  of  the  ribs  and  the  costal  cartilages,  the  rhachit'w  rosary, 
and  at  the  wrists  and  ankles,  double  joints,  are  almost  invariably 
present  in  well-marked  cases.  The  more  general  distortions  are 
in  part  the  effect  of  atmospheric  pressure,  in  part  the  effect  of 
the  force  of  gravity  and  habitual  postures,  and  in  some  instances 
muscular  action  or  injury  may  deform  the  softened  bones.  These 
deformities  differ  greatly  according  to  the  time  of  onset  of  the 
disease,  and  with  its  duration  and  severity.  The  head  may  be 
long  and  oblong  in  shape,  or  rectangular,  caput  qnadratum,  and 
it  sometimes  presents  prominences  in  the  frontal  and  parietal 
regions  due  to  thickening  of  the  bone,  and  on  the  posterior 
aspect  depressed  and  softened  areas,  cramotahes.  The  fontanelles 
are  abnormally  large,  and  they  may  remain  open  long  after  the 
usual  time  of  closure. 

The  thorax  is  compressed  from  side  to  side,  the  compression 
being  most  marked  in  the  middle  region,  where  the  ribs  have  the 
longest  cartilages  and  the  least  direct  support.  As  secondary 
results  the  back  of  the  thorax  is  flattened  and  the  sternum  is  thrust 
forward,  forming  the  pigeon  breast.  The  lower  ribs  are  everted 
to  accommodate  the  distended  abdomen,  potbelly.  In  well- 
marked  cases  the  rhachitic  chest  presents  two  distinct  grooves, 
one  transverse  in  the  axillary  line,  Harrison's  groove,  and  the 
other  passing  upward  by  the  side  of  the  rhachitic  rosary.  These 
deformities  are  in  great  degree  caused  by  atmospheric  pressure, 
but  they  are  increased  if  the  child  assumes  the  sitting  posture 
habitually.  In  this  attitude  the  body  is  inclined  forward,  the 
clavicles  are  distorted,  and  the  spine  is  bent  into  a  more  or  less 
rigid  posterior  curve,  most  marked  in  the  lower  dorsal  and 
lumbar  regions,  the  rhachitic  kyphosis.  Less  often  there  may  be  a 
lateral  deviation  or  scoliosis. 

The  arms  may  be  distorted  by  the  efforts  of  the  child  to  sup- 
port the  body  in  the  sitting  posture,  or  by  active  exertion,  as  in 
creeping  (Fig.  284).  Occasionally  the  deformities  may  be  local- 
ized at  the  elbows,  and  sufficiently  marked  to  merit  the  name 
cubitus  varus  or  valgus,  corresponding  to  genu  valgum  or  varum  ; 
or  the  principal  distortion  may  be  a  dorsal  convexity  of  the  lower 
extremity  of  the  radius. 

The  bones  of  the  lower  extremities  are  often  distorted,  primarily 
by  the  habitual  postures  assumed  in  sitting  or  creeping,  and  these 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     489 

deformities  are  usually  exaggerated  when  the  erect  attitude  is 
assumed.  In  some  instances  it  would  appear  that  the  femoral 
necks  are  twisted  backward  somewhat ;  this  distortion  may- 
explain  in  part  the  limitation  of  inward  rotation  that  is  some- 
times observed  in  rhachitic  children.  Depression  of  the  femoral 
neck  (coxa  vara)  may  be  present  also,  although  this  deformity 
does  not,  as  a  rule,  attract  attention  until  a  much  later  period  of 
life.  The  changes  in  the  pelvis  are  of  special  interest  to  the 
obstetrician.     These  are  essentially  an  increase  in  the  sacrover- 

FlG.  284. 


General  rhachitic  deformities,  showing  distortions  of  the  arms  and  legs 
induced  by  posture. 


tebral  prominence,  due  to  the  forward  and  downward  displace- 
ment of  the  sacrum,  an  abnormal  expansion  of  the  ilia,  caused  by 
pressure  of  the  abdominal  contents,  and,  in  some  instances,  a 
decrease  of  the  lateral  diameter,  an  effect  of  the  pressure  of  the 
femora  upon  the  yielding  bone. 

In  the  milder  type  of  rhachitis  in  older  children  who  walk,  the 
deformities  are  often  confined  to  the  trunk  and  lower  extremities. 
In  such  cases,  in  addition  to  the  changes  in  the  bones,  there  is 
usually  a  ])rominont  abdomen  and  increased  lordosis,  combined 


490  ORTHOPEDIC  SURGERY. 

with  slight  habitual  flexion  of  the  thighs  and  lower  legs,  the 
rhachitic  attitude. 

If  the  disease  is  of  sudden  onset  and  is  severe  and  general  in 
its  manifestations,  it  may  be  accompanied  bj  pain,  by  sensitive- 
ness of  the  affected  bones,  and  by  such  weakness  of  the  lower 
extremities  as  may  simulate  paralysis,  rhachitic  pseudoparalysis. 
It  is  probable,  however,  that  the  cases  in  which  the  pain  is 
extreme,  "■  acute  rhachitis,"  are,  in  reality,  scurvy  or  scurvy  and 
rhachitis  combined,  scurvy  rickets  so-called. 

Rhachitis,  as  described,  is  the  type  ordinarily  seen  in  hospital 
practice,  and  its  manifestations  are  unmistakable.  In  its  milder 
form  it  is  not  particularly  uncommon  among  the  children  of  the 
well-to-do,  whose  hygienic  surroundings  are  good.  In  such 
cases  the  most  marked  symptom  is  weakness.  The  child  is 
often  fat  and  well  developed,  although,  as  a  rule,  pale.  The 
abdomen  is  somewhat  enlarged  and  slight  prominences  at  the 
epiphyseal  junctions,  particularly  at  the  wrists,  may  be  made  out. 
The  legs  appear  small  in  proportion  to  the  body,  and  the  liga- 
ments are  lax,  so  that  if  the  child  stands  the  feet  are  flat  and 
assume  the  attitude  of  valgus.  In  this  class,  in  which  the  child 
is  said  to  have  weak  ankles,  knock-knee  is  common. 

The  most  common  symptom  of  rhachitis  of  the  mild  type  is  the 
failure  of  the  child  to  attempt  to  walk  at  the  usual  time,  about 
sixteen  months.  If  a  child  who  is  not  ill  and  who  has  not 
suffered  from  exhausting  disease  does  not  walk  at  two  years  of 
age  it  is  probably  rhachitic. 

Prognosis.  The  duration  of  the  progressive  stage  of  rhachitis 
depends,  of  course,  upon  the  age  of  the  patient  and  upon  the  treat- 
ment. In  cases  that  are  untreated  and  in  which  the  predisposing 
causes  continue,  the  period  of  repair  may  be  delayed  for  several 
years  or  longer,  as  shown  by  the  fact  that  the  child  makes  little 
effort  to  stand.  But,  in  most  instances,  the  rhachitic  child  begins 
to  walk  at  some  time  during  the  third  year,  and  at  this  time  the 
deformities  of  the  lower  extremity,  knock-knee,  bow-leg,  flat-foot, 
and  the  like  usually  develop  or  become  aggravated,  while  those 
of  the  upper  extremity  may  become  less  noticeable. 

The  deformities  of  rhachitis  tend  to  disappear  or  to  become 
less  marked  with  growth  ;  the  concavities  of  the  distorted  shafts 
are  filled  by  accretions  of  periosteal  bone,  which  is  again  absorbed 
from  the  interior  as  the  medullary  canal  straightens  itself.  The 
thickened  diaphyses  and  enlarged  epiphyses  become  more  sym- 
metrical under  the  influences  of  rapid  growth  and  increased  func- 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     491 

tioual  activity,  but  traces  of  severe  rhachitis  always  remain,  and 
many  of  the  more  noticeable  and  permanent  distortions  of  the 
trunk  and  of  the  lower  extremities  are  due  to  this  cause. 

The  prognosis  as  to  the  outgrowth  of  rhachitic  deformities 
depends  upon  the  duration  and  the  severity  of  the  disease  and 
upon  the  function  of  the  deformed  part.  Rhachitic  distortions 
of  the  arms  almost  always  disappear.  Tlie  rhachitic  chest  is 
rarely  seen  in  the  adolescent  or  adult.  The  rhachitic  kyphosis 
is  corrected  or  modified  when  the  erect  posture  is  assumed,  but 
rhachitic  scoliosis,  on  the  other  hand,  usually  increases  with  the 
growth.  Distortions  of  the  lower  extremities  may  occasionally 
entirely  disappear,  and  in  most  cases  they  are  less  marked  in  the 
adult  than  in  the  child.  Stunting  of  the  growth  is  a  constant 
effect  of  severe  and  prolonged  rhachitis  ;  it  depends  in  part  upon 
the  arrest  of  development  during  the  active  stage  of  disease  and 
in  part  upon  the  changes  in  the  bones  that  cause  premature 
consolidation  at  the  epiphyses. 

Treatment.  The  treatment  of  rhachitis  consists  essentially  in 
a  reversal  of  the  conditions  under  which  it  developed.  It  is, 
therefore,  dietetic,  hygienic,  and  medicinal.  Deformity,  the 
ef3^ect  of  the  disease,  may  be  prevented  by  guarding  the  weakened 
bones  from  overstrain,  and  it  may  be  remedied,  if  it  be  present, 
by  manipulation  or  by  mechanical  or  by  operative  treatment. 

The  more  detailed  treatment  of  rhachitis  may  be  found  in 
works  on  Pediatrics.  In  general,  the  diet  in  the  cases  developing 
in  early  infancy  should  be  of  milk,  especially  modified  according 
to  the  need  of  the  patient.  At  a  later  time,  corresponding  to  the 
normal  period  of  weaning,  the  diet  should  be  largely  animal,  to 
the  exclusion  of  starchy  food,  cream  and  fresh  butter  being  espe- 
cially valuable. 

The  patient,  protected  by  proper  woollen  underclothing,  should 
pass  as  much  time  as  possible  in  the  open  air,  and  should  sleep 
in  a  well-ventilated  room.  Daily  salt  baths  are  recommended 
for  older  children,  and  regular  massage  of  the  extremities  and  of 
the  abdomen  should  be  employed.  Medicinal  treatment  is  of 
secondary  importance.  The  bowels  should  be  regulated  and 
digestion  should  be  aided  by  proper  remedies.  For  anaemia, 
which  is  usually  present,  the  syrup  of  the  iodide  of  iron  is  of 
value  ;  cod-liver  oil  serves  both  as  a  food  and  medicine,  when  it 
is  readily  assimilated.  It  is  unlikely  that  any  drug  has  a  very 
direct  influence  on  the  disease.  Phosphorus  in  doses  of  ^i-^  to 
yi-|^   of   a   grain   is  often   given,  and   is   supposed  to  lessen   the 


492  ORTHOPEDIC  S  UB GER  Y. 

abnormal  congestion  of  the  bones,  while  the  deficiency  of  lime 
salts  may  be  supplied  possibly  by  the  administration  of  lime  in 
some  form,  the  syrup  of  the  lactophosphate  of  lime  being  a 
favorite  prescription. 

The  prevention  of  deformity,  other  than  by  the  means  already 
enumerated,  consists  in  preventing  habitual  postures  that  predis- 
pose to  deformity,  and  in  daily  massage  and  manipulative  cor- 
rection of  incipient  distortions.  Young  infants  and  those  whose 
bones  are  especially  vulnerable  should  spend  much  of  the  time 
in  the  reclining  posture.  The  Bradford  frame  or  similar  appli- 
ance is  especially  useful  in  the  treatment  of  this  class  of  cases. 
The  treatment  of  the  more  advanced  deformities,  by  support  or 
by  operation,  is  described  elsewhere. 

"Late  Rickets." 

Late  rickets  is,  as  the  name  implies,  an  affection  presenting 
all  the  characteristics  of  the  common  infantile  form.  This,  in 
rare  instances,  appears  in  later  childhood  or  even  in  adolescence  ; 
in  some  cases  the  affection  appears  to  be  a  continuation  or 
recrudescence  of  the  infantile  form  ;  in  others  no  history  of  a 
preceding  affection  can  be  obtained.^ 

By  many  writers  the  term  late  rickets  is  improperly  used  to 
explain  the  deformities  of  adolescence,  genu  valgum,  coxa  vara, 
and  the  like,  although  none  of  the  distinctive  signs  of  the  affec- 
tion may  be  present.  Local  rickets  is  less  objectionable  as 
applied  to  the  same  class  of  cases. 

Chondrodystrophia. 

Synonyms.     Foetal  rhachitis,  achondroplasia. 

Cases  that  present  the  signs  of  what  appears  to  be  severe 
general  rhachitis  at  birth  are  not  especially  uucommon.  The 
trunk  is  disproportionately  long  as  compared  to  the  stunted 
limbs  ;  the  head  is  large,  the  chest  presents  a  pigeon-like  distor- 
tion, and  the  epiphyses  appear  to  be  generally  enlarged.  In 
some  instances  the  back  is  curved  into  a  rigid  kyphosis,  or  scoliosis 
and  restricted  motion  or  apparent  fixation  of  many  of  the  joints 
may  be  present. 

Etiology  and  Pathology.  These  cases  were  formerly  sup- 
posed to  be  instances  of  intra-uterine  rhachitis  ;  chondrodystrophia 

1  Drewitt.    Transactions  of  the  London  Pathological  Society,  1881,  vol.  sxxii.    Clutton, 
St.  Thomas'  Hospital  Reports,  1884,  vol.  xiv. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     493 

is  not,  however,  the  result  of  a  disturbance  of  nutrition  ;  it  is  due 
apparently  to  a  congenital  defect  in  the  bones  themselves  or  rather 
of  the  original  cartilage.  Khachitis  is  characterized  by  hyper- 
trophy of  the  epiphyseal  cartilages  and  by  delayed  ossification. 
In  chondrodystrophia,  on  the  contrary,  there  is  atrophy  of  the 
epiphyseal  cartilages  and  abnormal  rapidity  of  ossification.  On 
section  of  a  bone  the  shaft  is  seen  to  be  thickened  and  stunted, 

Fig.  285. 


Chondrodystrophia  of  slight  degree,  contrasted  with  ordinary  rhaehitis,  in  sisters.  1.  Chon- 
drodystrophia. Broad,  short,  very  flexible  hands ;  trunk  disproportionately  long ;  knock- 
knees.  Age,  five  and  a  half  years  ;  height,  SOJ^  inches ;  normal  height,  40  inches.  2.  Rha- 
ehitis, bow-legs  ;  age,  four  years  ;  height,  32}^  inches ;  normal  height,  36  inches. 


the  epiphyses  are  enlarged  also,  and  these  hypertrophied  and 
prematurely  ossified  segments  may  overhang  the  diminutive  car- 
tilage   that  intervenes. 

Chondrodystrophia,  or  an  affection  resembling  it,  is  sometimes 
seen  (Fig.  285)  in  a  v(!ry  mild  form  ;  the  appearance  of  the  child 


494  ORTHOPEDIC  S  UB  GEB  Y. 

suggests  rhachitis,  but  the  stunting  of  the  growth  is  greater  than 
is  ever  the  result  of  rhachitis  of  corresponding  severity. 

Cretinism.  Cretinism  may  cause  a  similar  dwarfing  of  the 
stature,  and  cretinism  may  be  combined  with  chondrodystrophia, 
but  in  most  instances  the  symptoms  of  mental  deficiency  that 
accompany  cretinism  are  lacking  in  this  affection. 

Treatment.  The  treatment  of  so-called  foetal  rhachitis  con- 
sists in  regular  massage  and  manipulation  of  the  distorted  parts 
and  of  the  anchylosed  joints.  This  treatment  may  extend  over 
several  years,  during  which  the  limbs  and  back  must  be  protected. 

Rest  on  the  Bradford  frame  during  the  period  of  active  treat- 
ment is  advisable.  If  congenital  cretinism  is  suspected  the 
administration  of  thyroid  extract  would  be  indicated. 

Prognosis.  By  persistent  treatment  the  range  of  motion  in 
the  stiffened  joints  may  be  regained,  but  the  prognosis  as  to 
growth  is  bad.  The  patients  present  in  later  years  the  abnor- 
mally long  trunk  and  stunted  extremities  that  were  present  at 
birth. 

Infantile  Scorbutus. 

Synonyms,     Scurvy,  scurvy  rickets. 

Scurvy  in  infancy,  as  at  other  periods  of  life,  is  a  constitutional 
disease  dependent  upon  impaired  nutrition,  caused  apparently  by 
the  deprivation  of  proper  food.  The  disease  was  originally 
described  by  Smith  and  Barlow  as  scurvy  rickets,  but  it  may, 
and  often  does,  occur  independently  of  the  latter  affection. 

Pathology.  The  pathological  changes  most  often  found  in 
cases  of  the  advanced  type  are  hemorrhages  beneath  the  mucous 
membranes  and  the  periosteum.  Separation  of  the  epiphyses 
may  occur. 

Symptoms.  The  disease  is  most  often  observed  in  bottle-fed 
infants  from  six  to  eighteen  months  of  age.  In  some  instances  the 
patients  are  evidently  ill-nourished,  but  in  others  they  may  appear 
to  be  in  good  condition.  The  early  symptoms  resemble  rheu- 
matism. The  child  shows  evidences  of  discomfort  when  certain 
joints,  usually  of  the  lower  extremity,  are  moved,  and  as  the 
disease  progresses  it  may  scream  whenever  it  is  turned  or  lifted. 
The  painful  joints  are  sensitive  to  pressure  and  they  may  be 
somewhat  enlarged,  but  local  heat  and  redness,  as  well  as  fever, 
are,  as  a  rule,  absent.  After  dentition  the  gums  may  be  swollen 
and  spongy,  and  hemorrhages  into  the  skin  or  beneath  the  mucous 
membranes  may  occur.     In  extreme  cases  the  swelling  about  a 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     495 

joint  due  to  effusion  of  blood  and  accompanied,  it  may  be,  by 
separation  of  the  epiphysis  may  be  mistaken  for  the  symptoms 
of  infectious  epiphysitis  or  even  for  sarcoma. 

Treatment.  The  treatment  consists  primarily  in  the  regula- 
tion of  the  diet,  particularly  in  the  substitution  of  fresh  milk, 
properly  modified,  for  the  patent  food  or  sterilized  milk  that 
may  have  been  employed.  This  should  be  suj)plemented  by 
orange  juice,  or  that  of  other  fresh  fruit.  The  change  of  diet 
usually  relieves  the  symptoms.  During  the  painful  stage  of  the 
disease  complete  rest  in  the  horizontal  position  on  a  pillow  or 
frame  may  be  indicated  ;  later,  massage  of  the  limbs  and  back 
may  be  of  service  in  improving  the  nutrition,  and  remedying 
slight  deformity. 

Fragilitas  Ossium. 

Synonym.     Idiopathic  osteopsathyrosis. 

Idiopathic  fragility  or  osteopsathyrosis  is  of  congenital  origin. 
The  bones  appear  to  be  weak  simply  because  of  a  failure  in  the 
formation  of  periosteal  bone.  In  such  cases  there  may  be  dis- 
tortions at  birth,  apparently  caused  by  intra-uterine  fractures, 
and  in  after-life  fracture  may  follow  the  slightest  accident  or  even 
sudden  motion.  Blanchard^  has  reported  a  case  in  which  there 
were  seventy  distinct  fractures  between  the  ages  of  two  months 
and  twenty-seven  years.  A  similar  case  was  for  many  years 
under  treatment  in  the  Hospital  for  Ruptured  and  Crippled. 
For  a  part  of  the  time  the  trunk  and  legs  were  inclosed  in  a 
plaster-of -Paris  casing  to  prevent  the  fractures  that  followed  even 
ordinary  movements.  At  the  age  of  fourteen  the  strength  of  the 
bones  had  increased  sufficiently  to  enable  the  patient  to  walk 
about  with  the  support  of  braces,  but  he  was,  in  stature,  about 
the  size  of  a  child  of  seven  years. 

Fractures  in  this  class  of  cases  are  attended  with  but  little 
pain.  They  unite  slowly  with  but  a  small  callus.  It  is  prac- 
tically impossible  to  prevent  a  certain  amount  of  deformity. 
With  advancing  years  the  liability  to  fracture  may  diminish, 
but,  as  a  rule,  the  patient  is  disabled  and  dwarfed  in  stature. 

The  treatment  is  protective.  Massage  is  of  some  service  in 
improving  local  nutrition.      Medication  is  of  little  avail.^ 

There  are  many  other  conditions  that  cause  local  or  general 

'  Transactions  American  Orthopedic  Association,  vol  y\. 

2  Poralf.    Bull,  et  M6m.  de  la  Soc.  Obst.  et  Gyn.  de  Paris,  1840.    Salvetti,  Beitr.  zur  Path. 
Anat.  und  Allg.  Path.,  1894,  Bd.  xvi. 


496  OB THOPEDIC  SURGER  Y. 

fragility  of  the  bones  and  thus  an  increased  liability  to  fracture. 
For  example,  the  weakness  of  old  age,  sometimes  called  senile 
rickets  ;  the  atrophy  caused  by  disuse  incidental  to  chronic  joint 
disease,  or  the  weakness  that  may  be  caused  by  certain  diseases  of 
the  nervous  system.  In  other  instances  the  weakening  may  be 
the  direct  result  of  disease,  as,  for  example,  osteomalacia  or 
rhachitis.     (See  Atrophy  of  Bone,  page  241.) 

Osteomalacia. 

Synonym.     Mollitis  ossium. 

Osteomalacia  is  a  disease  of  an  inflammatory  nature,  charac- 
terized by  an  absorption  of  the  earthy  substances  (decalcification) 
of  the  bones  and  by  deformity.     The  disease  is  one  of  adult  life. 

Fig.  286. 


Osteomalacia  in  a  child. 


It  is  far  more  common  among  females  than  males,  and  pregnancy, 
in  about  half  of  the  cases  that  have  been  reported,  seemed  to  be 
the  exciting  cause.  The  disease  usually  begins  insidiously.  The 
symptoms  are  pain  on  motion,  referred  to  the  pelvis  and  to  the 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.    497 

thighs.  This  is  supposed  to  be  of  rheumatic  origin  until  the 
character  of  the  affection  is  made  evident  by  the  weakness  of  the 
limbs  and  by  the  deformities.  These  deformities  are  of  greater 
interest  to  the  obstetrician  than  to  the  surgeon,  for  when  the 
affection  complicates  pregnancy  the  distortion  of  the  pelvis  may 
be  so  great  as  to  prevent  normal  delivery. 

Osteomalacia  in  Childhood.  Three  cases  of  osteomalacia  in 
childhood  have  been  reported  by  Siegert/  and  one  case  has  come 
under  my  observation.  The  patient,  one  of  twelve  living  chil- 
dren of  healthy  parents,  was  nursed  by  his  mother  for  the  usual 
period,  and  until  the  age  of  four  years  he  appeared  to  be  perfectly 
healthy.  At  this  time,  without  known  cause,  general  weakness 
became  apparent,  and  at  the  same  time  deformities  of  the  lower 

Fig.  287. 


Osteitis  deformans  in  a  female  seventy-three  years  of  age.    (Lunn.^) 

extremities  developed.  At  the  age  of  six  years  he  was  unable  to 
stand.  At  the  present  time  the  condition  of  the  patient,  now 
nine  years  of  age,  is  shown  in  Fig.  286.  There  is  no  evidence 
of  rhachitis  or  of  paralysis.  The  patient  has  never  suffered 
from  pain  or  discomfort.  The  lower  extremities  are  somewhat 
atrophied  from  disuse,  the  bones  are  abnormally  flexible  and  are 
distorted  to  a  moderate  degree.  The  epiphyses  are  not  enlarged 
(Fig.  282). 

Treatment.  As  the  etiology  of  the  affection  is  unknown, 
the  treatment  is  therefore  experimental  or  symptomatic  and 
palliative. 

Local  Osteomalacia.  When  deformity  of  a  bone  appears  and 
increases  without  apparent  cause  it  is  often  assumed  that  a  local 
disease — "local  rickets  or  local  osteomalacia" — is  present. 

'  Mdnch.  med.  Wochenschr.,  November  1,  1898. 

-  Prince.    American  Journal  of  tlie  Medical  Sciences,  November,  1902. 
32 


498 


ORTHOPEDIC  SURGERY. 


Local  weakness  and  deformity  may  be  caused  by  injury  or  by 
subacute  osteomyelitis  and  the  like.  If  there  is  a  distinct  local 
disease  that  deserves  the  name  of  local  osteomalacia,  its  cause  has 
not  been  determined. 

Osteitis  Deformans. 

This  disease  was  first  described  by  Paget^  in  1877.  It  is  a 
chronic  inflammatory  affection  of  the  bones,  characterized  by 
hypertrophy  and  softening.  "  The  bones  enlarge,  soften,  and 
those  bearing  weight  become  unnaturally  curved  and  misshapen." 


Fig.  288. 


Fig.  289. 


Normal  tibia  and  foot. 


Osteitis  deformans.    Hyperostosis  and  decalci- 
fication. (Fitz.)    Contrast  with  Fig.  289. 


Section  of  an  affected  bone  shows  it  to  be  markedly  increased 
in  size,  and  somewhat  in  length,  by  a  combination  of  rarefying 
and  formative  osteitis.  The  inner  layers  become  porous,  and  at 
the  same  time  new  bone  is  deposited  beneath  the  periosteum. 

The  disease  appears  to  be  confined  to  adult  life,  and  it  is 
apparently  more  commoD  among  males  than  females.  Of  67 
cases  collected  by  Packard,  Steele,  and  Kirkbride,^  61  per  cent, 
were  in  males.     Occasionally  but  a  single  bone  is  affected.     Such 


1  Med.  Chir.  Trans.,  1882,  vols.  xl.  and  Ixv. 

2  American  Journal  of  the  Medical  Sciences,  November,  1901. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     499 

are,  in  all  probability,  early  cases,  for,  as  a  rule,  the  lesions  are 
symmetrical  and  general  in  distribution,  the  bones  of  the  lower 
extremity,  the  skull,  and  the  spine  being  more  often  involved. 
Thus  the  head  progressively  increases  in  size,  and  the  legs  become 
bowed.  If  the  spine  is  affected  it  bends  forward,  forming  a  long, 
more  or  less  rigid  kyphosis. 

Aside  from  the  deformities  and  the  characteristic  enlargement 
of  the  bones,  the  symptoms  are  not  marked.  At  times  complaint 
is  made  of  pain  usually  supposed  to  be  rheumatic  until  the  char- 
acteristic changes  in  the  bones  appear.  The  disease  is  extremely 
chronic  in  its  course,  and,  as  a  rule,  the  general  health  is  not 
seriously  affected.  In  several  instances  sarcoma  of  bone  finally 
caused  death  many  years  after  the  onset  of  the  disease.  Its 
etiology  is  unknown,  and  its  treatment  is  palliative. 

Secondary  Hypertrophic  Osteo-arthropathy.^ 

Osteo-arthropathy  is  an  inflammatory  disease  of  the  bone  char- 
acterized by  hypertrophy,  clubbing  of  the  fingers,  and  effusion 
into  certain  of  the  joints.  The  hypertrophy  is  caused  by  a 
deposition  of  layers  of  bone  beneath  the  periosteum  of  the  meta- 
carpal and  metatarsal  bones,  the  phalanges  and  the  distal 
extremities  of  the  adjoining  bones  of  the  arms  and  legs.  Less 
often  the  area  of  the  disease  is  more  extensive,  involving  the 
femora,  the  humeri,  and  the  spine  even. 

Osteo-arthropathy  is  usually  a  complication  of  pre-existing 
chronic  disease,  most  often  of  the  lungs.  The  patient  first 
notices  clubbing  of  the  terminal  phalanges  and  hypertrophy  of 
the  finger-nails,  later  an  increasing  enlargement  of  the  wrists  and 
ankles  and  of  the  hands  and  feet,  accompanied  by  discomfort, 
sensitiveness  to  pressure,  and  often  by  effusion  into  the  neighbor- 
ing joints,  symptoms  that  would  be  classed  as  rheumatic  were  it 
not  for  the  evident  hypertrophy. 

The  clubbing  of  the  fingers  is  due,  in  part  at  least,  to  impair- 
ment of  the  circulation,  and  the  connection  of  the  disease  of  the 
bones  with  that  of  the  lungs  has  suggested  the  theory  that  it  is 
caused  by  the  absorption  of  toxins,  and  that  its  etiology  is  similar 
to  the  amyloid  hypertrophy  of  the  internal  organs  that  sometimes 
follows  chronic  disease  of  bones  and  joints  attended  by  suppuration. 

The  treatment  is   symj)tomatic,  and  as  the  affection  is  almost 

'  Marie.    Revue  Mi^-dicale,  Paris,  1890,  x.  p.  1.    Bamburger,  Wiener  Idin.  Woch.,  1889,  No. 
11 ;  Deutsche  Chlr.,  1899.  L.  28. 


500  ORTHOPEDIC  SURGERY. 

always  secondary  to  a  graver  disease  but  little  is  known  of  its 
outcome.  It  is  certain,  however,  that  the  secondary  osteo-arthro- 
pathic  symptoms  become  less  marked  or  may  even  disappear  as 
the  patient  recovers  from  the  original  disease  of  the  lungs  or 
other  organs.  The  affection  is  very  uncommon  in  childhood. 
In  one  characteristic  case  observed  by  the  writer  complete  recovery 
followed  the  cure  of  Pott's  disease  and  chronic  bronchitis,  the 
hypertrophied  phalanges  alone  remaining.^ 

Acromegalia. 

This  affection  is  also  characterized  by  progressive  enlargement 
of  the  hands  and  feet,  but  it  differs  from  osteo-arthropathy  in  that 
all  the  tissues  are  involved  in  the  hypertrophy.  The  hypertrophy 
of  the  bone  is  limited  to  the  epiphyseal  extremities,  and  is  slight 
compared  with  that  of  the  soft  parts.  The  face  is  often  involved, 
the  tissues  of  the  nose,  lips,  and  ears  being  enlarged  and  thickened, 
together  with  the  underlying  bones,  so  that  the  expression  is  very 
markedly  changed. 

Acromegalia  is  common  among  those  of  gigantic  stature,  the 
local  hypertrophy  and  the  gigantism  both  being  due,  it  is  sup- 
posed, to  disease  of  the  pituitary  gland. 

Diagnosis,  The  three  affections  that  have  been  described — 
osteitis  deformans,  osteo-arthropathy,  and  acromegalia — are  rare 
diseases,  and  they  are  of  little  practical  interest  to  the  surgeon 
other  than  from  the  standpoint  of  diagnosis.  This  might  be 
somewhat  difficult  if  the  pathological  process  were  confined  to  a 
single  bone  or  limb,  as  is  sometimes  the  case  in  osteitis  deformans. 

The  essential  characteristics  of  the  three  diseases  may  be  sum- 
marized as  follows  :  In  osteitis  deformans  the  entire  bone  is 
increased  in  size  and  length,  and  because  of  the  coincident  weak- 
ening of  its  structure  it  becomes  distorted  ;  the  skull  is  usually 
involved,  but  the  hands  and  feet  are  not  often  affected.  It  is  a 
disease  of  middle  or  later  life,  and  there  are,  as  a  rule,  no  symp- 
toms other  than  those  due  to  the  local  changes  in  the  bones. 

In  osteo-arthropathy  the  process  is  an  hypertrophy  of  a  slight 
degree,  caused  by  deposition  of  periosteal  bone,  especially  about 
the  distal  extremities  of  the  shafts  of  the  bones  adjoining  the 
hands  and  feet.  It  is  not  often  accompanied  by  the  weakness  or 
the  deformity  that  is  characteristic  of  the  preceding  affection  ; 
the  skull  is  not  usually  involved,  but  the  long  bones  of  the  hand 

1  Whitman.    Pediatrics,  February  15, 1899. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS.     501 

and  feet  are  thickened,  so  that  these  members  are  markedly 
increased  in  size.  There  is  often  coincident  discomfort  and  swell- 
ing of  the  neighboring  joints.  As  a  rule,  the  local  affection  of 
the  bones  is  secondary  to  chronic  disease  of  the  lungs. 

In  acromegalia  the  marked  changes  are  hypertrophic  enlarge- 
ments of  the  hands  and  feet  in  which  all  the  tissues  are  involved  ; 
the  hypertrophy  of  the  bones  is  most  marked  about  the  epiphyses, 
the  diaphyses  remaining  unaffected  ;  thus  it  differs  from  the 
preceding  disease,  in  which  similar  enlargement  of  the  extremities 
occurs.  The  head  is  often  involved,  but  the  hypertrophy  is  of 
all  the  structures  of  the  face,  not  of  the  skull,  as  in  osteitis 
deformans. 

The  disease  appears  to  be  confined  to  early  adult  life,  and 
it  is  often  preceded  or  accompanied  by  symptoms  of  a  general 
nature,  headache,  mental  impairment,  and  the  like. 

The  changes  in  the  bones  characterizing  the  affections  may  be 
easily  demonstrated  by  means  of  the  Roentgen  pictures. 


CHAPTER    XY. 

CONGENITAL  DISLOCATION  OF  THE  HIP  AND  COXA  VARA. 

Congenital  Dislocation  at  the  Hip-joint. 

Of  all  the  congenital  dislocations,  or,  perhaps,  more  properly, 
misplacements,  that  of  the  hip-joint  is  by  far  the  most  common 
and  the  most  important. 

Statistics.  Congenital  dislocation  of  the  hip  is  much  more 
common  in  females  than  in  males.     In  671  cases  collected  from 


Fig.  290. 


^^ 


Congenital  dislocation  of  the  hip,  showing  the  elongated  capsule  and  the  right-angled 
relation  of  the  neck  to  the  shaft  of  the  femur.    (William  Adams.) 

different  sources  by  Lorenz,  589  (87.8  per  cent.)  were  in  females 
and  82  (12.2  per  cent.)  in  males.  Of  1039  cases  seen  at  the 
Polyclinic  in  Milan,  867  (83.4  per  cent.)  were  in  females,  172 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     503 

(16.6  per  cent.)  in  males.^  In  500  cases  from  the  records  of  the 
Hospital  for  Ruptured  and  Crippled,  investigated  for  me  by  Dr. 
C.  P.  Flint,  413  (82.6  per  cent.)  were  in  females  and  87  (17.4 
per  cent.)  in  males. 

The  dislocation  is  more  often  unilateral  than  bilateral.  In 
Lorenz's  series  of  671  cases  421  (64.4  per  cent.)  were  single  ; 
225  of  the  right,  196  of  the  left  side.  In  245  cases  (36.6  per 
cent.)  the  displacement  was  bilateral. 

Statistics  of  Five  Hundred  Cases  of  Congenital  Dislocation  of 
Hip,  Recorded  at  the  Hospital  for  Ruptured  and  Crippled. 

Per  cent. 

Males 87  17.40 

Females 413  82.60 

500  100.00 

Right  hip 135  27.66 

Left  hip 218  44.47 

Both 136  27.87 

489  100.00 

Not  specified 11 

500 
Males. 

Right  hip 25  30  48 

Left  hip 32  39.04 

Both 25  30.48 

82  100.00 

Not  specified 5 

87 
Females. 

Right  hip 110  27.04 

Left  hip 186  55.69 

Both Ill  27.27 

407  100.00 

Not  specified 6 

413 

The  dislocation  at  the  time  when  the  patients  are  brought  for 
treatment  is  usually  posterior,  upon  the  dorsum  of  the  ilium  ;  in 
other  instances  it  is  anterior,  and  the  head  of  the  bone  may  be 
felt  beneath  the  anterior  superior  spine.  It  is  probable,  however, 
that  the  primary  displacement  is  often  directly  upward,  for  in 
those  cases  discovered  in  infancy  this  position  is  common. 

Pathology.  The  pathological  anatomy  of  the  dislocation  was 
first  clearly  demonstrated  by  Dupuytren  in  1826,  and  since  1890, 
when  the  open  operation  was  first  performed,  the  exact  relation 
and  the  appearances  of  the  different  components  of  the  joint  have 
been  described  in  detail  by  Hoffa,  Lorenz,  and  other  operators. 


1  Bernacchi.    Zeits.  Orth.  Chir.,  vol.  ii.  p.  275. 


504 


OB  THOPEDIC  S  UR  QEB  Y. 


Fig.  291. 


The  condition  of  the  joint  varies  with  the  age  of  the  patient 
and  the  strain  and  friction  to  which  the  displaced  parts  have 
been  subjected.  In  early  infancy  it  may  be  assumed  that  the 
head  of  the  bone  lies  in  close  proximity  to  what  is,  in  some 
instances,  a  practically  normal  acetabulum ;  in  others  to  one  that 
is  somewhat  rudimentary,  often  shallow  and  small,  sometimes  of 
an  oval  or  of  a  somewhat  triangular  shape.  The  acetabulum  is 
covered  with  normal  hyaline  cartilage,  the  ligamentum  teres  is 
present,  and  the  capsule  is  of  nearly  normal  structure.  At  a  later 
time,  when  the  joint  is  exposed  at  operation  at  the  age  of  five  or 
more  years,  the  capacity  of  the  rudimentary  acetabulum  may  be 
lessened  by  a  deposit  of  fat  and  fibrous  tissue.  As  a  rule,  how- 
ever, it  appears  to  be  of  fair  size  and  ""depth.  The  capsule  is 
elongated  to  accommodate  the  upward  displacement  of  the  femur. 
It  is  hypertrophied,  especially  where  it  covers  the  upper  part  of 

the  head  of  the  bone,  and  it 
may  be  drawn  into  a  shape 
like  an  hour-glass  ;  the  up- 
per part  contains  the  head 
of  the  bone  ;  the  anterior  wall 
is  drawn  tightly  across  the 
acetabulum,  forming  at  its 
upper  border  a  narrow  slit- 
like communication,  through 
which  the  ligamentum  teres 
passes  if  it  be  present  (Fig. 
286).  The  interior  of  the 
capsule  is  in  part  lined  with 
synovial  membrane,  and  it 
often  contains  more  synovial 
fluid  than  is  found  in  the 
normal  joint. 

The  ligamentum  teres,  al- 

Congeuital  dislocation  of  the  hip,  showing  the    ^-l^oUffh    probably    present    at 
original  and  the  acquired  acetabula.    (Lorenz.)  8       F  J     r 

birth  in  a  large  proportion  of 
the  cases,  becomes  attenuated  and  ribbon-like  with  the  increasing 
elongation  of  the  capsule,  and  after  the  age  of  five  years,  or  at 
the  time  when  the  open  operation  is  performed,  it  is  usually  absent, 
and  far  more  often  in  the  bilateral  than  in  unilateral  cases. 
According  to  Lorenz,  in  52  cases  between  two  and  a  half  and 
five  years  it  was  present  in  17  ;  in  48  cases  beyond  the  age  of 
five  years  it  was  present  in  but  4.     In  rare  instances  it  may  be 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     505 

hypertrophied.  In  my  own  experience  the  ligament  is  present 
in  a  very  much  larger  proportion  of  the  cases,  although  it  is  often 
so  rudimentary  that  it  might  easily  be  overlooked. 

A  shallow  secondary  acetabulum,  formed  in  part  by  the  direct 
pressure  of  the  head  of  the  bone  through  the  adherent  capsule, 
and  in  part  the  result  of  irritation  of  the  periosteum,  is  usually 
found  upon  the  ilium  (Fig.  292),  but  it  is  not  often  of  sufficient 
depth  to  assure  a  secure  support  for  the  head  of  the  femur  ;  thus 

Fig.  292. 


Congenital  dislocation  of  the  hip  in  adult  age,  showing  the  abnormal  shape  of  the  ace- 
tabulum, the  depressions  in  the  ilium  caused  by  the  pressure  and  friction  of  the  head  of  the 
femur,  and  the  destructive  effect  of  this  pressure  and  friction  upon  the  femur.    (Adams.) 


its  upper  margin  gradually  recedes  or  two  distinct  depressions 
may  be  formed,  one  above  the  other.  The  upper  extremity  of 
the  femur  is  usually  somewhat  atrophied.  The  neck  is  often 
shorter  than  normal,  and  its  angle  may  be  lessened,  and  in  many 
instances  its  forward  inclination  is  increased.  The  head  of  the 
bone  may  be  nearly  normal,  although  usually  it  is  somewhat 
flattened  on  its  inner  and  under  surface,  or  it  may  be  somewhat 
conical,  acorn-like  in  shape,  or  again  compressed  from  side  to 
side  to  an  almond  shape  or  otherwise  distorted.      The  abnormal- 


506 


ORTHOPEDIC  SURGERY. 


ities,  in  part  congenital,  become  more  marked  with  age,  and  in 
adult  specimens  the  head  and  neck  of  the  femur  may  be  so 
atrophied  and  worn  away  that  it  has  little  semblance  of  normal 
contour  (Fig.  292). 

There  are  also  secondary  changes  in  the  bones  of  the  pelvis. 
In  unilateral  dislocation  the  pelvis  is  usually  somewhat  atrophied 


Fig.  293. 


Fig.  294. 


Unilateral  dislocation,  showing  the  inclination 
of  the  body  toward  the  shorter  leg. 


The  same  patient  before  operation, 
showing  the  abnormal  lordosis  and  rota- 
tion of  the  pelvis.    (See  Figs.  320  and  321.) 


on  the  affected  side,  and  a  lateral  inclination  of  the  spine  may  be 
present.  The  tinal  changes  in  the  pelvis  caused  by  the  bilateral 
dislocation  are  more  important  ;  its  inclination  is  increased,  the 
lumbar  lordosis  is  exaggerated,  the  sacrum  is  forced  forward  and 
downward  so  that  the  anteroposterior  diameter  is  lessened  ;  the 
tuberosities  of  the  ischia  are  everted  and  the  transverse  diameter 
of  the  pelvic  outlet  is  increased. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     507 

The  long  muscles  of  the  thigh  are  shortened,  while  those 
attached  about  the  trochanter  are  changed  in  direction  and  are 
usually  lengthened.  There  is  also  a  slight  general  muscular 
atrophy  that  is  particularly  marked  in  the  gluteal  group. 

The  changes  that  have  been  described  are  in  great  degree 
secondary  to  the  displacement.  They  are  in  part  congenital,  in 
part  accommodative,  and  in  part  due  to  the  influences  of  attrition 
and  injury,  to  which  the  abnormal  mobility  predisposes.  Thus, 
as  a  rule,  they  become  more  marked  with  increasing  age,  and  in 
some  of  the  adult  specimens  but  little  resemblance  to  the  normal 
parts  remains. 

As  a  rule,  congenital  dislocation  of  the  hip  is  not  accompanied 
by  defective  development  or  deformity  elsewhere,  although  cases 
are  sometimes  seen  in  which  a  general  laxity  of  ligaments  is 
present  or  in  which  the  dislocation  may  be  one  of  a  series  of 
deformities  and  malformations. 

Etiology.  Nothing  positive  is  known  of  the  etiology  of  the 
dislocation.  In  a  small  proportion  of  the  unilateral  cases  it  may 
be  due  to  violence  at  birth,  but  the  fact  that  nearly  85  per  cent, 
of  the  patients  are  females  makes  it  evident  that  the  primary 
cause  can  be  neither  injury  nor  disease. 

Hereditary  influence  can  be  established  in  a  few  instances. 
The  writer  has  examined  three  female  children  in  a  family  of 
nine,  in  each  of  whom  there  was  dislocation  of  the  left  hip,  the 
order  being  the  third,  eighth,  and  ninth  child.  Also  twins  in 
another  family,  one  having  single  and  the  other  double  disloca- 
tion. And  in  four  instances  congenital  displacement  was  present 
in  the  mothers  of  patients. 

Of  the  various  theories  that  have  been  advanced  to  account  for 
the  condition,  the  most  reasonable  seems  to  be  defective  develop- 
ment. This  defective  development  may  affect  the  entire  acetabu- 
lum, or  it  may  involve  only  its  posterior  margin,  or  the  cause  of 
the  displacement  may  be  an  abnormal  laxity  of  the  capsule  that 
predisposes  to  displacement  when  the  thigh  is  flexed  and  ad- 
ducted. 

It  is  evident  that  the  defective  development  may  be  the  cause 
of  the  luxation,  or  it  may  be  an  effect  of  displacement  or  mal- 
position which  in  turn  may  be  due  to  an  abnormal  or  constrained 
attitude  of  the  fretus. 

The  predisposing  attitude  is  doubtless  flexion  and  adduction  of 
the  thigh,  and  dislocation  at  this  joint  is  relatively  frequent 
because  the  acetabulum   is  shallow  in  foetal  life.     According  to 


508 


ORTHOPEDIC  SURGERY. 


Fig.  295. 


Sainton's  observations,  in  newborn  children  it  covers  but  one- 
third  of  the  femur,  but  at  the  age  of  five  years  it  is  sufficiently 
deep  to  contain  one-half  of  it. 

Heusner^  and  Marcwald,  from  an  examination  of  eighty-five 
foetuses,  conclude  that   the  greater  liability  of  females    to  the 

dislocation  is  explained  by 
the  disproportionate  laxity 
of  the  capsule  as  compared 
with  males. 

It  is  probable  that  the  dis- 
location, in  some  cases  at 
least,  is  at  birth  a  subluxa- 
tion only,  that  becomes  com- 
plete through  muscular  ac- 
tion and  by  the  use  of  the 
limb  in  standing  and  walk- 
ing. 

Symptoms.  The  dis- 
placement does  not,  as  a 
rule,  attract  attention  until 
the  child  begins  to  walk, 
although  in  some  cases  the 
mother  may  have  noticed  a 
peculiar  breadth  of  pelvis,  or 
a  "  lump  "  on  the  buttock, 
or  a  "  snapping  ' '  about  the 
hip-joint,  or  a  peculiar  atti- 
tude of  the  limb  before  this 
time. 

Unilateral  Dislocation.  If 
the  displacement  is  of  one 
side,  a  lim'p  is  immediately 
apparent,  which  becomes 
more  noticeable  as  the  child 
grows  older.  The  limp  is  peculiar,  and  its  character  is  ex- 
plained by  its  cause ;  for  the  shortened  limb,  owing  to  the 
elasticity  of  the  capsule,  becomes  still  shorter  when  the  weight 
falls  upon  it;  thus  in  walking  there  is  a  peculiar  lunge  of  the 
body  toward  the  short  side,  that  has  been  likened  to  the  motion 
in  walking  down  stairs.     In  the  ordinary  form  the  head  of  the 


Congenital  dislocation  of  both  hips,  illustrating 
the  separation  of  the  thighs,  the  abnormal  breadth 
of  the  pelvic  region,  and  the  prominent  trochanters. 


1  Zeits.  f.  Orth.  Chir.,  1902,  Bd.  x.  H.  4. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.      509 

femur  is  displaced  upward  and  backward,  and  in  compensation 
the  pelvis  is  tilted  toward  the  short  limb  and  its  inclination  is 
increased  ;  it  is  thus  twisted  downward  and  forward  so  that  the 
anterior  superior  spine  lies  at  a  lower  level  and  in  advance  of 
that  of  the  opposite  side  (Figs.  293  and  294). 

Fig.  296. 


Bilateral  congenital  dislocation  of  the  hip,  showing  the  exaggerated  lordosis. 


At  an  early  age  the  shortening  of  the  limb,  due  to  the  elevation 
of  the  trochanter,  is  from  one-half  to  three-quarters  of  an  inch. 
In  later  childhood  the  elevation  is  from  one  and  one-half  to  two 
inches,  and  in  adult  life  it  may  be  considerably  more. 

The  effect  of  the  displacement  is  also  shown  by  a  flattening  of 
the  huttock,  and   usually  the  elevated  and  prominent  trochanter 


510  oUthopebic  s  ub  gee  y. 

may  be  seen  as  an  abnormal  lateral  projection,  on  a  level  with 
the  anterior  superior  spine,  which  is,  as  has  been  stated,  some- 
what tilted  downward. 

In  childhood  motion  in  the  false  joint  is  more  free  than  normal, 
and  the  abnormal  mobility  can  be  demonstrated  by  alternate 
traction  and  upward  pressure  on  the  limb,  but  as  the  femur 
becomes  larger  and  the  upward  displacement  increases,  the 
mobility  is  restricted.  The  range  of  abduction  is  much  diminished, 
and  in  extreme  cases  the  limb  may  become  permanently  adducted 
and  flexed,  thus  adding  the  apparent  shortening  of  adduction  to 
that  caused  by  the  dislocation  (Fig.  297). 

Bilateral  Dislocation,  When  the  dislocation  is  bilateral  the 
shortening  of  the  limbs  is,  as  a  rule,  equal  or  nearly  so,  and  if,  as 


Fig.  297. 


Jf 


/ 


Congenital  dislocation  in  an  adolescent,  illustrating  the  flexion  contraction 
in  a  well-marked  case. 

is  usual,  both  femora  are  displaced  backward,  the  pelvis  is  tilted 
forward  ;  thus  in  compensation  "  the  hollow "  of  the  back  is 
increased,  the  abdomen  protrudes,  the  buttocks  are  flattened,  the 
pelvis  appears  to  be  abnormally  wide,  and  the  thighs  are  sep- 
arated by  a  considerable  interval  (Figs.  295  and  296).  The  limp 
characteristic  of  the  single  displacement  is  replaced  by  an  exag- 
gerated waddle,  a  "  sailor  gait." 

General  Symptoms.  In  early  childhood  there  are  no  special 
symptoms  other  than  the  limp  or  the  waddle,  but  as  the  child 
becomes  more  active  it  usually  complains  of  discomfort  after 
exertion.  It  is  easily  fatigued,  and  at  times  it  may  suffer  actual 
pain.  These  symptoms  are,  of  course,  more  marked  in  the  double 
than  in  the  single  displacement,  because  in  the  latter  case  the 
normal  limb  is  capable  of  bearing  more  than  its  share  of  the  strain. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     511 


Fig.  298. 


The  symptoms  often  increase  during  adolescence,  but  they  may 
become  less  troublesome  in  adult  life,  when  the  head  of  the  bone 
may  have  found  a  permanent  resting  place  on  the  pelvis  ;  a 
security  which  is  often  assured  by  a  corresponding  limitation  of 
the  range  of  motion.  The  shortening  and  the  secondary  effects 
of  the  displacement,  of  course,  persist,  so  that 
the  individual  is,  as  compared  with  the  normal 
standard,  more  or  less  disabled  and  deformed. 

The  great  majority  of  the  patients  are 
females,  and,  because  of  the  less  laborious 
occupations  and  the  distinctive  dress,  the  dis- 
ability and  its  effects  are  less  serious  than  if 
the  displacement  were  more  equally  divided 
between  the  sexes. 

Anterior  Dislocation.  The  symptoms  of 
the  unilateral  anterior  dislocation,  in  which 
the  head  of  the  bone  lies  beneath  the  anterior 
superior  spine,  are  much  less  marked  than  in 
the  ordinary  form  because  the  relation  of  the 
pelvis  to  the  femur  is  nearly  normal ;  so  that 
secondary  deformity  is  slight.  The  shorten- 
ing is  less  and  the  limp  is  less  noticeable 
because  the  resistance  of  the  tissues  attached 
to  the  anterior  superior  spine  is  sufficient  to 
assure  a  relatively  secure  support. 

In  bilateral  anterior  dislocation  the  entire 
body  is  swayed  slightly  backward,  but  the 
lumbar  lordosis  is  not  increased ;  in  fact,  the 
back  is  often  peculiarly  flat.  Otherwise  the 
symptoms  do  not  differ,  except  in  degree, 
from  those  of  the  posterior  displacement 
(Fig.  298). 

Supracotyloid  Displacement.  As  has  been 
stated,  in  early  cases  the  displacement  may 
be  a  form  of  subluxation  in  which  the  head  lies  but  slightly 
above  the  normal  position.  The  same  upward  displacement  is 
occasionally  found  in  older  subjects.  The  physical  signs  are 
similar  to  those  of  the  anterior  displacement. 

Diagnosis.  The  diagnosis  offers  no  difficulty.  The  history 
of  the  limp  or  waddle  noticed  when  the  child  began  to  walk  and 
yet  unaccompanied  by  pain  or  preceded  by  injury  or  disease  is  in 
itself  sufficiently  distinctive.      If  the  displacement  is  of  one  side, 


\ 


Bilateral  anterior  con- 
genital dislocation.  The 
lordosis  is  far  less  marked 
than  in  the  ordinary  form. 


512 


OB  THOPEDIC  S  UB  QEB  Y. 


measurement  demonstrates  the  shortening  as  compared  with  the 
other  limb,  a  shortening  that  is  explained  by  the  prominence  and 
the  elevation  of  tlie  trochanter  above  N^laton's  line.  Traction 
and  upward  pressure  on  the  leg  will  demonstrate  the  abnormal 
mobility  of  the  displaced  head  ;  and  finally,  if  the  thigh  be  flexed 
and  adducted  to  its  extreme  limit,  the  neck  and  head  of  the  femur 
can  be  easily  distinguished  moving  under  the  gluteal  muscles 
when  the  limb  is  rotated.      Thus  it  may  be  differentiated  from 

Fig.  299. 


Bilateral  congenital  dislocation  of  the  hip. 

depression  of  the  neck  of  the  femur  {coxa  vara),  in  which,  although 
the  trochanter  is  elevated,  the  neck  and  head  of  the  bone  cannot 
be  felt,  and  in  which  the  abnormal  mobility,  characteristic  of  the 
dislocation,  is  absent.  Again,  coxa  vara  is  almost  never  a  con- 
genital affection ;  therefore,  the  history  itself  would  practically 
exclude  it. 

Upward  displacement  of  the  femur  not  infrequently  folloAvs 
infectious  epiphysitis  or  arthritis  of  infancy  or  early  childhood. 
In  such  cases  a  part  of  the  upper  extremity  of  the  bone  is  usually 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     513 


destroyed,  so  that  the'head  cannot  be  distinguished  on  palpation. 
Although  the  other  physical  signs  are  similar  to  those  of  the 
congenital  displacement,  the  scars  about  the  joint  show  the  evi- 
dence of  former  disease,  and  the  history  is  almost  always  available 
for  diagnosis.  Thus,  as  a  rule, 
such  disabilities,  as  well  as  trau- 
matic dislocations  or  other  re- 
sults of  injury  or  disease,  are 
readily  excluded. 

The  bilateral  dislocation  pre- 
sents, of  course,  the  same  physi- 
cal signs  as  the  single  form  ;  it  is 
even  more  easily  recognized  by 
the  peculiar  appearance  and  dis- 
tinctive gait  of  the  patient. 

The  waddling  gait  may  be 
simulated  by  that  of  extreme 
how-legs,  but  the  hip-joints  are, 
in  this  deformity,  normal  in  ap- 
pearance and  function.  The 
waddling  of  lumbar  Potfs  dis- 
ease is  also  somewhat  similar, 
but  this  is  an  acquired  painful 
disease  of  the  spine,  in  which  the 
hip-joints  are  normal  in  appear- 
ance and  usually  so  in  function. 

Pseudohypertro'phic  paralysis 
may  be  mentioned  as  causing  a 
somewhat  similar  gait  and  at- 
titude, but  here  the  resemblance 

ceases.  Bilateral  dislocation  in  adolescence.    This 

Ai         1  J.    1     1     .1        T  patient  was  practically  disabled  by  pain  and 

s  has  been  stated,  the  diag-   weakness. 

nosis  of    congenital   dislocation 

can  be  easily  made  by  physical  examination  ;  the  only  real  diffi- 
culty is  experienced  in  certain  dislocations  or  subluxations  of  the 
anterior  type  in  which  a  secure  secondary  acetabular  support  has 
formed,  and  in  cases  seen  in  early  infancy  in  which  the  dislocation 
may  be  incomplete,  but  opportunity  for  such  early  diagnosis 
is  rarely  offered.  In  doubtful  cases  a  Roentgen  picture  will 
demonstrate  the  (character  of  the  disability  (Fig.  299). 

Treatment.      Dupuytren,  in  1829,  after  a  careful  study  of  the 
anatomy  of  the  deformity,  came  to  the  conclusion  that  it  was  not 

33 


514  ORTHOPEDIC  SURGERY. 

only  incurable  but  that  palliation  of  its  effects  even  was  hardly 
attainable ;  and  for  sixty  years  the  statement  was  generally 
accepted,  although  cures  were  attained  in  all  probability  by 
Pravaz,  of  Lyons,  1847,  and  at  a  much  later  time  by  Paci,  of 
Pisa,  1887. 

The  term  dislocation  naturally  suggests  that  cure  implies 
replacement  and  retention  of  the  displaced  bone  in  its  proper 
place,  and  in  1890  Hoffa,  now  of  Berlin,  first  performed  this 
operation  with  success  by  opening  the  joint  from  behind  and 
enlarging  the  rudimentary  acetabulum  to  a  size  sufficient  to  con- 
tain the  head  of  the  bone.  The  details  of  the  operation  were 
afterward  modified  by  Lorenz,  of  Vienna,^  and  at  the  present 
time  the  original  operation  has  been  to  a  great  extent  abandoned 
for  bloodless  reposition,  but  to  Hoffa  belongs  the  credit  for  the 
introduction  of  the  modern  treatment  of  this  disability. 

The  Lorenz   Operation   of  Bloodless   Reduction,  Retention, 
and  Weight  Bearing. 

This  treatment  is  based  on  the  experience  obtained  by  the 
open  treatment  that  an  acetabulum  of  fair  size  is  practically 
always  present.  This  acetabulum  is  not  of  sufficient  capacity  to 
retain  the  head  of  the  femur  when  the  limb  is  in  the  normal 
attitude,  but  it  is  sufficiently  deep  to  permit  of  retention  when 
the  limb  is  fixed  in  abduction. 

It  has  been  proved,  also,  that  by  traction  and  leverage  the 
head  of  the  femur  in  most  instances  can  be  forced  into  direct  con- 
tact with  the  rudimentary  acetabulum.  Once  this  contact  or 
reposition  is  attained,  the  limb  must  be  fixed  to  prevent  dis- 
placement, and  as  soon  as  possible  the  patient  must  stand  and 
walk  in  order  that  the  weight  of  the  body  and  functional  use  may 
deepen  the  rudimentary  acetabulum.  Meanwhile  the  distended 
capsule  and  other  tissues  contract  about  the  new  joint,  and  the 
muscles  become  accustomed  to  their  new  functions.  That  the 
acetabulum  may  be  actually  enlarged  by  the  presence  of  the  head 
of  the  femur  is  proved  by  the  fact  that  secondary  depressions  of 
sufficient  size  to  form  joints  of  fair  stability  are  often  found  upon 
the  pelvis  in  anatomical  specimens  from  older  subjects. 

The  first  step  in  the  operation  is  to  overcome  the  resistance  of 
the  tissues,  namely,  of  the  capsule  and  of  the  long  muscles  that 

1  Pathologie  und  Therapie  der  Angebornen  Hoeft  Verrenkung,  Wien,  1895  ;  Ueber  heilung 
der  Angebornen  Hoeftgelenk  Verrenkung,  Leipzig  u.  Wien,  1900. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     515 

have  become  structurally  shortened  in  accommodation  to  the 
upward  displacement  of  the  head  of  the  femur.  The  second  step 
is  to  reduce  the  dislocation,  or,  rather,  to  force  the  head  of  the 
femur  over  the  posterior  or  upper  border  of  the  acetabulum. 
The  third  is  to  increase  the  security  of  the  articulation  by 
stretching  the  anterior  border  of  the  capsule.  The  fourth  is  to 
fix  the  parts  securely  in  a  plaster  bandage. 

The  Lorenz  Operation.  The  patient  is  placed  upon  a  table  with 
a  thick  folded  sheet  beneath  the  buttocks.  The  assistant,  stand- 
ing opposite  the  operator,  fixes  the  pelvis  with  his  hands  (Fig. 
301).     In  some  instances  better  control  is  assured  by  pressing 

Fig.  301. 


Reduction  of  dislocation  of  the  right  hip.    First  step.    The  operator  breaks  down  the 
resistance  offered  by  the  adductors  by  forcible  massage. 


the  flexed  thigh  of  the  sound  side  downward  against  the  abdomen, 
as  in  the  Thomas  test  for  flexion  in  hip  disease. 

The  operator  first  flexes  the  thigh  to  a  right  angle  with  the 
body,  then  forcibly  abducts  it,  at  the  same  time  kneading  the 
tense  muscles  with  the  ulnar  border  of  the  hand,  stretching  and 
rupturing  the  fibres  until  the  normal  prominence  has  entirely 
disappeared.  The  stretching  is  continued  until  the  limb  can  be 
forced  down  to  the  plane  of  the  body.  One  next  overcomes  the 
shortening  of  the  ti.ssues  on  the  posterior  aspect  by  flexing  the 
lirnV),  extended  at  the  knee,  upon  the  trunk,  gradually  forcing  it 
downward  until  the  toes  may  be  placed  against  the  patient's  face 


516 


ORTHOPEDIC  SURGERY. 


Fig.  302. 


Forcible  flexion  of  the  extended  limb  on  the  abdomen.    Second  step  in  the  operation. 


Fig.  303. 


Forcible  extension  of  the  thigh.    Third  step  in  the  operation. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     517 

(Fig.  302).  During  this  manceuvre  the  assistant  fixes  the  pelvis 
by  holding  the  extended  thigh  of  the  sound  side  firmly  against  the 
table.  The  next  step  is  to  overcome  the  resistance  of  the  tissues 
on  the  front  of  the  joint.  The  pelvis  is  fixed  by  the  assistant. 
The  leg  is  then  flexed  upon  the  thigh,  and  the  thigh  is  forced 
downward  behind  the  plane  of  the  body,  or  the  patient  may  be 
turned  upon  the  side,  as  in  Fig.  303.  After  this  preliminary 
stretching  traction  is  made  upon  the  limb,  and  if  with  slight 
effort  the  trochanter  can  be  drawn  down  to  Nelaton's  line  reduc- 
tion is  attempted. 

Reduction,  The  pelvis  having  been  fixed  as  in  the  first  position, 
the  limb  is  slowly  and  forcibly  abducted  over  a  wedge  of  wood 
suitably  padded,  the  apex  of  which  is  placed  between  the 
trochanter  and  the  pelvis  (Fig.  304).     As  the  limb  is  gradually 

Fig.  304. 


Reposition.  The  thigli  is  forcibly  abducted  over  the  padded  wedge.  Fourth  step  in  the 
operation.  The  wedge  is  of  hard  wood  of  the  following  dimensions  :  length,  9>^  inches  ; 
height,  33^  inches ;  base,  3  inches. 

forced  downward  to  and  behind  the  plane  of  the  body,  the  head 
of  the  femur  is  forced  upward  until  it  finally  snaps  over  the  pos- 
terior border  of  the  acetabulum.  Reduction  is  usually  accompanied 
by  a  distinct  jar,  and  often  by  an  audible  thud.  It  is  also  indi- 
cated by  tension  upon  the  posterior  muscles  of  the  thigh  which 
causes  fixed  flexion  of  the  leg.  An  effort  is  now  made  to  increase 
the  capacity  of  the  joint.  The  patient  is  turned  upon  the  sound 
side  and  the  pelvis,  having  been  fixed  by  the  assistant,  the 
operator  draws  the  thigh  over  and  over  again  behind  the  plane 
of  the  body,  and  at  the  same  time  rotates  it  from  side  to  side. 
The  security  of  the  reposition  is  then  determined.  One  tests 
successively  the  stability  or  depth  of  the  superior  margin  of  the 
acetabulum  by  reducing  the  abduction  ;  of  the  posterior  margin  by 
lifting  the  thigh  ventral  ward,  and  in  a  similar  manner  the  inferior 
border.      Upon   this   examination   the  j)rognosis  is  made  ;  if  the 


518 


OB  THOPEDIC  S  UB  GEB  Y. 


stability  allows  an  approximation  to  the  normal  position  before 
displacement  occurs  the  prognosis  is  good.  If,  on  the  other  hand, 
the  margins  of  the  acetabulum  are  so  ill-formed  that  displacement 
occurs  very  easily  the  prognosis  is  bad. 

The  operation  is  varied  somewhat  in  certain  instances.  If 
after  the  stretching,  the  trochanter  still  remains  above  Nelaton's 
line,  one  attempts  to  overcome  the  remaining  resistance  by  direct 
traction  in  the  line  of  the  body.  Counter-resistance  is  furnished 
by  a  folded  sheet  passed  between  the  thighs  about  the  perineum, 
the  two  ends  of  which  are  tied  about  a  corner  of  the  table.  Trac- 
tion on  the  limb  is  made  by  one  or  two  assistants  while  the 


Fig.  305. 


Reposition  in  young  subjects,  the  thumb  being  used  as  the  fulcrum  to  reduce  the  left  hip. 

operator  supports  the  pelvis  and  presses  downward  and  inward 
upon  the  trochanter.  Occasionally  reposition  is  effected  during 
this  manoeuvre — that  is,  the  head  is  drawn  over  the  superior 
instead  of  the  posterior  border  of  the  acetabulum. 

Preliminary  Traction.  In  the  treatment  of  older  patients  or 
of  more  resistant  cases  preliminary  traction  in  bed  is  advisable. 
The  traction  must  be  considerable,  and  heavy  weights,  if  possible 
up  to  forty  pounds  or  more,  should  be  employed  for  two  or  more 
weeks.     This  is  of  great  advantage. 

Reduction  in  Young  Subjects.  In  younger  subjects  the  wedge  is 
not  necessary,  but  the  thumb  of  the  operator  may  be  used  as  a 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     519 

fulcrum  beneath  the  trochanter  to  lift  and  push  the  head  upward 
while  the  limb  is  abducted.  In  this  class  of  cases  much  less 
force  is  required  in  the  preliminary  stretching  (Fig.  305). 

After  reposition  has  been  accomplished  and  when  the  greatest 
possible  stability  is  assured  by  abducting  the  thigh  again  and 
again  and  forcibly  rotating  it  from  side  to  side  to  stretch  the  con- 
tracted anterior  wall  of  the  capsule  and  by  extending  the  leg  upon 
the  thigh,  to  thoroughly  overcome  the  resistance  of  the  hamstring 
muscles  the  plaster  bandage  is  applied.  A  close-fitting  stock- 
inette shirt,  of  which  one-half  has  been  cut  and  sewed  to  cover 
the  limb,  as  a  drawer,  is  drawn  on  over  the  limb,  threaded  as  it 
were,  with  a  long  bandage,  the  "  scratcher.'^  The  patient  is 
then  placed  upon  the  pelvic  rest  and  the  limb  is  held  in  the 

Fig.  306. 


The  position  in  which  the  limb  is  held  when  the  plaster  bandage  is  applied. 

position  of  greatest  stability  at  a  right  angle  with  the  trunk  and 
lying  behind  the  plane  of  the  body.  The  pelvis  and  thigh  are 
thoroughly  and  thickly  covered  with  layers  of  sheet-wadding  or 
cotton.  This  is  bandaged  firmly  with  cotton  flannel,  to  assure  a 
slight  elastic  compression  (Fig.  306). 

The  plaster  spica  is  then  applied.  This  should  be  thick  and 
firm,  at  least  a  dozen  and  oftentimes  many  more  of  the  ordinary 
size  being  used  by  Lorenz.  These  bandages  are  drawn  snugly 
around  the  pelvis  and  thigh  by  a  series  of  reverses  and  figure-of- 
eight  turns,  clasping  the  iliac  crests  and  thoroughly  covering 
in  the  buttock.  The  support  is  cut  away,  to  allow  motion  at  the 
knee-joint  and  the  ends  of  the  shirting  are  then  drawn  smoothly 
over  the  bandage  and  are  sewed  to  one  another  (Figs.  307  and  308). 


520 


ORTHOPEDIC  SURGERY. 


The  operation  is  usually  followed  by  swelling  and  discoloration 
in  the  adductor  region  and  more  or  less  pain,  especially  when 
the  leg  is  moved.  This  soon  passes  away,  usually  during  the 
first  or  second  week,  and  the  child  is  then  encouraged  to  stand. 
As  it  is  only  with  extreme  difficulty  that  the  foot  on  the  operated 
side  can  be  brought  to  the  floor,  a  cork -soled  shoe  from  one  and 
a  half  to  three  inches  in  height  is  usually  worn  to  facilitate 
walking. 

As  has  been  stated,  walking  is  encouraged  ou  the  theory  that 
weight  bearing  and  the  stimulation  of  functional  activity  will 
increase  the  stability  of  the  joint  by  deepening  the  acetabulum 
and  accentuating  its  boundaries.     In  most  instances  the  range 


Fig.  307. 


The  plaster  bandage  as  applied  by  Lorenz,  illustratiug  the  extreme  thickness  of  the 
pelvic  portion  and  discoloration  of  the  adductor  region. 


of  extension  at  the  knee  is  for  a  time  somewhat  restricted.  This 
restriction  is  overcome  by  passive  force  and  by  the  voluntary 
effort  of  the  patient.  The  first  bandage  is  allowed  to  remain  in 
place  for  from  six  to  eight  months,  the  skin  being  kept  in  good 
condition  by  daily  vigorous  rubbing  with  the  band  beneath  the 
supporting  bandage.  In  very  young  children  the  bandage  must 
be  changed  when  it  becomes  oft'ensive. 

In  this  time  (from  six  to  eight  months)  it  may  be  supposed 
that  the  accommodative  contraction  of  the  muscles  about  the  joint 
and  of  the  capsule  will  lessen  the  danger  of  redisplacement. 
The  limb  is  then  let  down  somewhat  so  that  the  patient  is  able 
to  walk  about   without  the  aid  of  a    high  shoe.      The  second 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     521 

bandage  is  retained  for  three  months  or  more,  and  it  is  then  re- 
moved, the  period  of  retention  being  from  eight  to  fourteen 
months,  according  to  the  stability  of  the  joint  at  the  time  of 
reduction.  In  the  treatment  of  very  young  children,  when  in 
testing  the  stability  after  reduction  the  femur  is  not  displaced, 
even  when  the  normal  position  is  approached,  the  limb  may  be 

Fig.  308. 


Unilateral  congenital  dislocation,  showing  the  fixation  bandage.  A  shoe  with  a  cork  sole 
about  two  inches  In  height  should  be  worn  on  the  operated  side,  while  the  attitude  of 
exaggerated  abduction  is  maintained. 

fixed  by  the  plaster  in  a  less  distorted  attitude — what  Lorenz 
calls  the  indifferent  position  of  flexion,  abduction,  and  outward 
rotation. 

So,  also,  when  the  tests  at  the  operation  show  fair  stability  a 
second  bandage  need  not  l)e  applied  after  a  preliminary  reten- 
tion of  from  six  to  nine  months,  but  it  is  better  to  err  on  the  side 
of  safety  in  the  matter  of  fixation. 


522  ORTHOPEDIC  SURGERY. 

When  the  retention  bandage  is  finally  removed  the  attitude  of 
moderate  abduction  and  outward  rotation  persists  for  a  time,  in 
some  instances  for  several  months.  This  being  an  indication  of 
stability,  is  considered  a  favorable  sign,  and  no  attempt  is  made 
to  correct  it.  In  the  after-treatment  the  limb  is  massaged,  par- 
ticularly the  posterior  and  lateral  muscles  of  the  hip,  and  the 
child  is  encouraged  to  abduct  and  to  extend  the  thigh.  Passive 
movements  are  made,  also,  in  the  direction  of  abduction  and 
extension,  the  ability  to  reproduce  the  first  or  operation  position 
during  the  early  treatment  being  considered  essential.  In  certain 
instances  the  child  for  a  time  should  sleep  in  this  position,  the 
attitude  being  assured  by  a  triangular  cushion  placed  between  the 
limbs  and  strapped  to  the  thigh  and  pelvis. 

Fig.  309. 


Illustrating  the  limitation  of  the  range  of  ahduction  in  the  attitude  of  right  angular 
flexion  in  bilateral  dislocation.    Compare  with  Fig.  311. 

Bilateral  congenital  dislocation  is  treated  in  exactly  the  same 
way  as  the  unilateral.  Both  hips  are  operated  upon  at  one 
sitting,  and  are  fixed  in  the  typical  attitude  (Fig.  304).  Walking 
is,  of  course,  difficult,  but  the  child  is  usually  able  to  stand,  and 
after  several  months  it  is  often  able  to  get  about  on  its  feet  after 
a  fashion  (Fig.  312). 

When  the  second  bandage  is  applied  the  limbs  are  let  down 
somewhat,  but  the  degree  depends,  of  course,  on  the  initial 
stability.  The  after-treatment  is  the  same  as  for  the  single 
dislocation,  except,  of  course,  that  the  subsequent  period  of 
awkwardness  is  much  longer.  Massage  and  exercises  (Fig.  310) 
are  far  more  important  than  in  single  dislocation,  as  the  weakness 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     523 

is  greater.     The  primary  position  during  sleep  may  be  assured 
by  a  cushion  or  roll  placed  between  the  thighs. 

Prognosis.  The  Lorenz  operation  is  not  without  danger.  The 
death-rate  attributed  to  aneesthesia  is  disproportionately  large  in 
the  cases  reported,  and  in  this  the  violence  of  the  manipulations 
may  be  an  important  factor. 

Fig.  310. 


The  after-treatment  following  the  removal  of  the  bandage  in  a  case  of  bilateral 
dislocation,  illustrating  hyperextension  of  the  thighs. 

In  450  operations  reported  by  Lorenz,  the  following  accidents 
occurred  : 

Fracture  of  the  neck  of  the  femur  in 11  cases. 

Fracture  of  the  pelvis  in 3      " 

Peroneal  paralysis  in 3      " 

Crural  paralysis  in 5      " 

Sciatic  paralysis  in 3      " 

In  the  last  cases  the  paralysis  persisted ;  in  the  others  it  was 
temporary.  In  1  case  the  femoral  artery  was  ruptured,  the 
patient  recovering  without  ill-effect.  In  1  case  gangrene  of  the 
extremity  necessitated  amputation  at  the  hip-joint. 

It  may  be  stated,  however,  that  in  the  younger  class  of  cases 
the  operation,  if  conducted  with  reasonable  regard  to  the  resist- 
ance o£  the  tissues  and  to  the  susceptibility  of  the  patient,  is 
practically  free  from  danger. 

In  cases  treated  at  the  proper  age — that  is,  under  six  years  for 
bilateral  and  under  eight  for  unilateral  cases — nearly  50  per  cent. 


524 


ORTHOPEDIC  SURGERY. 


of  the  unilateral  and  25  per  cent.  (50  per  cent,  for  each  side)  of 
the  bilateral  cases  can  be  anatomically  and  functionally  cured. 


Fig.  311. 


Illustrating  the  range  of  normal  abduction  of  the  thighs,  from  the  attitude  ot  right 
angular  flexion. 


Fig.  312. 


The  bandage  applied  after  the  reduction  of  bilateral  dislocation,  showing 
_   a  favorite  method  of  progression  on  a  chair. 

Nearly  all  the  others  can  be  greatly  improved,  in  that  the  pos- 
terior displacement  may  be  converted  into  an  anterior  one.     In 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     525 


Fig.  313. 


such  cases,  in  which  the  head  of  the  femur  is  forced  forward 
below  the  anterior  superior  spine,  the  static  conditions  become 
approximately  normal,  and  further  displacement  is  to  a  great 
extent  prevented  by  the  firm  tissues  attached  at  this  point.  A 
stable  articulation  is  assured  by  long  retention  of  the  limb  in  the 
position  of  abduction  and  extension  by  means  of  the  plaster 
bandage  and  by  exercises  and 
passive  movements  after  its 
removal. 

As  has  been  stated,  in  success- 
ful cases  the  head  of  the  femur 
can  always  be  palpated  directly 
beneath  the  femoral  artery.  The 
first  indication  of  failure  is  a 
slight  lateral  displacement  of  the 
head  to  the  outer  side  of  the 
artery.  This  may  appear  even 
during  the  period  of  fixation,  but 
often  not  until  the  plaster  ban- 
dage is  removed.  At  first  there 
is  no  shortening,  but  slowly,  as 
the  displacement  increases  and  as 
the  head  of  the  bone  ascends 
from  the  neighborhood  of  the 
acetabulum  to  that  beside  or 
above  the  anterior  inferior  pelvic 
spine,  this  becomes  evident.  At 
first  it  is  half  an  inch,  later  an 
inch,  but  it  is  not  often  more  than 
this,  at  least  during  childhood. 

It  has  been  stated  that  this 
outcome  may  be  expected  in  about 
half  of  the  favorable  cases  as  to 
age  in  which  all  the  details  of 
the  operation  have  been  properly 
carried  out,  and  it  is  the  usual 
result  in  the  unfavorable  class. 
This  result,  which  is  not  classed 
by  Lorenz  as  a  failure,  but  rather  as  an  improvement,  may  be 
explained  in  certain  instances  by  interposition  of  a  fold  of  cap- 
sule between  the  head  of  the  bone  and  the  acetabulum,  or  by 
failure  of  the  process'of  reformation  of  the  acetabulum.     In  most 


The  cure  of  congenital  dislocation.    The 
same  patient  is  shown  in  Fig,  308. 


526  OB THOPEDIC  S  UB  GEB  Y. 

cases,  however,  it  is  accounted  for  by  an  anterior  twist  of  the 
upper  extremity  of  the  femur,  so  that  the  neck  instead  of  point*- 
ing  inward  and  slightly  forward  from  the  shaft  is  turned  forward 
and  slightly  inward.  Thus,  in  order  to  replace  the  head  in  the 
acetabulum,  the  limb  must  be  rotated  inward  until  the  foot  points 
inward  rather  than  forward. 

Occasionally  the  presence  of  this  deformity  may  be  ascertained 
before  operation.  It  may  be  suspected,  for  example,  in  nearly  all 
the  anterior  and  supracotyloid  displacements  in  older  subjects, 
and  it  could  be  demonstrated,  doubtless,  by  a  series  of  Roentgen 
pictures.  In  most  cases,  however,  the  failure  of  treatment  calls 
attention  to  the  probable  existence  of  the  deformity.  It  is,  of 
course,  apparent  that  the  only  remedy  is  a  cutting  operation. 
Lorenz  is  content  in  these  cases  with  anterior  apposition,  but  if 
it  is  probable  that  a  twist  in  the  upper  extremity  of  the  femur  is 
alone  responsible  for  failure,  it  seems  more  reasonable  to  remove 
this  by  osteotomy.  This  operation  will  be  described  in  connec- 
tion with  the  open  operation. 

The  Treatment  of  Older  Subjects.  It  has  been  stated  that 
the  final  result  in  a  very  large  proportion  of  the  operations  was 
anterior  transposition  or  apposition,  as  Lorenz  calls  it,  and  that 
in  cases  beyond  the  age  of  eight  years  this  result  is  to  be  expected. 
In  this  class  of  cases — from  ten  to  twenty-one  years  of  age — it  is 
the  primary  aim  of  the  operation.  After  preliminary  traction  in 
bed  and  after  subcutaneous  division  of  the  more  resistant  tendons 
if  this  is  necessary,  the  limb  is  forced  into  moderate  abduction 
and  extreme  extension,  so  that  the  head  of  the  bone  is  displaced 
forward  to  the  neighborhood  of  the  anterior  inferior  spinous 
process.  In  this  attitude  the  limb  is  retained  for  many  months 
by  means  of  the  plaster  bandage,  and  it  is  assured  in  the  after- 
treatment  by  the  manipulation  and  exercises  already  described. 
Although  even  in  the  most  successful  cases  a  limp  persists,  yet 
it  is  far  less  noticeable  than  in  untreated  cases,  the  discomfort  is 
relieved,  the  limb  is  lengthened,  and  the  danger  of  future  disa- 
bility is  much  lessened. 

In  those  unusual  cases  in  which  the  adduction  and  flexion 
deformity  is  extreme,  osteotomy  of  the  femur  may  be  required, 
and  if  the  pain  is  persistent  excision  of  the  hip  may  be  necessary. 

The  Treatment  of  Congenital  Dislocation  in  Infancy.  Occa- 
sionally one  has  an  opportunity  to  treat  congenital  disloca- 
tion in  early  infancy.  The  details  of  treatment  do  not  differ 
essentially  from  those  already  described,  except,  of  course,  that 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     527 

reduction  is  easily  effected  (Fig.  305)  and  that  walking  or  weight- 
ing (functional  use  in  other  words)  cannot  be  utilized  at  once  in 
the  after-treatment.  In  this  class  of  cases,  provided  the  test  of 
the  stability  of  the  joint  is  satisfactory,  one  need  not  fix  the 
limb  in  the  extreme  position.  It  is  well,  however,  to  carry  the 
bandage  below  the  knee  in  order  to  assure  for  a  time  more 
complete  fixation.  The  support  must  be  renewed  whenever 
sanitary  reasons  indicate  the  necessity.  In  many  instances  cure 
is  practically  assured  in  a  few  months. 

Variations  in  the  Treatment.  It  has  been  stated  that  the  first 
indication  of  failure  was  ordinarily  a  slight  lateral  displacement 
of  the  head  to  the  outer  side  of  the  femoral  artery,  and  that  this 
displacement  was  favored  by  the  anteversion  of  the  neck  of  the 
femur.  As  is  well-known,  anteversion  of  moderate  degree  is  not 
unusual  in  the  femora  of  apparently  normal  joints.  In  such 
instances  subluxation  is  prevented  by  the  cotyloid  cartilage,  and 
by  the  normal  capsule  which  are  wanting  in  the  congenital  dis- 
location. When,  therefore,  anteversion  is  suspected  or  is  known 
to  exist  it  is  well  to  rotate  the  thigh  inward,  so  that  the  head  of 
the  femur  is  slightly  to  the  inner  side  of  the  artery,  and  to  fix 
it  in  this  attitude  by  extending  the  plaster  bandage  below  the 
knee,  the  leg  being  slightly  flexed  upon  the  thigh.  This  attitude 
should  be  retained  until  it  may  be  assumed  that  the  capsule  is 
sufficiently  contracted  to  restrain  the  femur  from  reluxation.  As 
has  been  stated,  the  writer  considers  the  additional  security 
attained  by  carrying  the  bandage  below  the  knee  of  some  impor- 
tance in  treatment  of  infants  and  young  children. 

Arthrotomy.  If  the  Lorenz  operation  has  failed  when  all  the 
details  have  been  thoroughly  carried  out,  the  advisability  of  an 
exploratory  operation  suggests  itself.  Under  proper  aseptic  pre- 
cautions this  should  entail  no  danger,  nor  should  it  compromise 
the  functional  ability  of  the  joint.  One  can  then  assure  one's 
self  that  the  head  of  the  bone  is  actually  replaced  within  the 
acetabulum.  Arthrotomy  is  indicated  also  if  the  resistance  to 
reposition  by  the  ordinary  method  is  so  great  that  dangerous 
force  must  be  exerted  to  overcome  it. 

The  joint  is  exposed  by  a  lateral  incision  about  three  inches  in 
length,  extending  downward  from  a  point  about  three-quarters 
of  an  inch  to  the  outer  side  of  the  anterior  superior  spine  of  the 
ilium,  the  fascia  is  divided,  and  the  line  of  junction  between  the 
tensor  vaginae  femoris  and  the  gluteus  niedius  muscles  is  found. 
These  muscles  are  then  separated  and  are  drawn  to  either  side  by 


528 


OR  THOPEDIC  S  UR  GER  Y. 


retractors,  thus  exposing  the  capsule  of  the  joint.  This  is 
opened  by  an  incision  parallel  to  the  neck  of  the  bone.  The 
finger  is  then  passed  through  the  opening,  down  upon  the  rudi- 
mentary acetabulum.  A  strong  cervix  dilator  is  next  inserted 
and  the  contracted  capsule  is  thoroughly  stretched.  If  the 
ligamentum  teres  is  present  it  is  removed. 


Fig.  314. 


Fig.  315. 


^ 


A  successful  result  after  the  open  operation, 
illustrating  a  useful  form  of  brace  to  be  used  in 
the  after-treatment  to  hold  the  limb  in  proper 
position,  if  it  has  a  tendency  to  rotate  outward. 


Bilateral  dislocation  six  months 
after  replacement  by  the  open  meth- 
od in  1897,  illustrating  the  change 
in  the  contour  of  the  trunk. 


The  head  is  then  replaced  ;  the  capsule  and  overlying  tissues 
are  united  with  catgut  sutures.  The  limb  is  then  fixed  in  the 
typical  position  by  the  Lorenz  spica.  In  the  majority  of  cases 
the  cause  of  the  failure  of  the  primary  operation  is  an  antever- 
sion  of  the  neck  of  the  femur.  In  this  event  after  replacement 
the  limb  must  be  rotated  inward  to  the  required  degree  and  fixed 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     529 

by  a  plaster  bandage  extending  below  the  knee  as  a  preliminary 
to  osteotomy. 

Osteotomy. 

When  the  limb  has  been  fixed  for  several,  preferably  six, 
months,  in  the  attitude  of  inward  rotation  so  that  stability  is  in 
some  degree  assured,  the  operation  for  correcting  the  anterior 
twist  of  the  upper  extremity  of  the  femur  should  be  performed. 

The  plaster  bandage  having  been  removed,  a  long  drill  should 
be  inserted  through  the  trochanter  and  into  the  neck  of  the  bone. 
This  indicates  the  position  of  the  neck  and  fixes  the  upper  frag- 

FlG.  S16. 


1 

^^H 

Hw 

1 

I^H 

Scoops  used  in  the  treatment  of  congenital  dislocation,  also  the  subcutaneous  osteotome. 


ment.  A  subcutaneous  osteotome  is  then  inserted  at  a  point 
just  below  the  trochanter  minor  or  at  the  lower  third  of  the 
femur,  and  a  thorough  division  of  the  bone  is  made.  The  lower 
osteotomy  is  perhaps  to  be  preferred,  because  one  has  better 
control  of  the  fragments  at  this  point.  When  the  division  is 
complete,  the  upper  fragment  being  fixed  by  the  drill,  the  limb 
is  rotated  outward  until  the  normal  relation  between  the  shaft 
and  the  neck  is  restored.  A  plaster  spica  including  the  foot 
is  then  applied,  })y  which  the  drill  and  tlie  upper  fragment  are 

34 


530 


ORTHOPEDIC  SURGERY. 


fixed  in  proper  relation  to  the  shaft.  Two  weeks  later,  when 
the  improved  position  is  assured,  this  is  withdrawn.  The  after- 
treatment  is  the  same  as  in  the  uncomplicated  cases. 


Fig.  317. 


Unsuccessful  treatment  by  forcible  correction  (Lorenz  operation).    The  posterior  has 
been  changed  to  an  anterior  displacement.    Rear  view. 


The  Open  Operation  with  Enlargement  of  the  Acetabulum.     The 
original  Hoffa-Lorenz  operation,  once  the  treatment  of  routine, 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     53] 

is  now  reserved  for  a  restricted  class  of  cases  in  which  the  blood- 
less operation  has  failed,  and  in  which  on  opening  the  joint  the 
acetabulum  is  found  to  be  notably  deficient. 

Supposing  the  shortening  of  the  limb  to  have  been  overcome 
by  previous  treatment,  the  joint  and  capsule  are  opened  in  the 
manner  already  described.  One  finger  is  then  inserted  to  the 
acetabulum  and  by  its  side  a  strong,  sharp,  bayonet-shaped  spoon 
(Fig.  316)  is  passed,  and  with  it  the  shallow  acetabulum  is 
enlarged  to  a  sufficient  size,  care  being  taken  to  accentuate  its 
superior  and  posterior  border.  The  head  is  then  placed  within 
it,  and  the  wound  is  closed  or  packed  according  to  the  custom 
of  the  operator.  A  long  plaster  spica  is  then  applied  with  the 
limb  in  an  attitude  of  moderate  abduction  and  extension.  In  a 
month,  or  when  repair  is  complete,  a  short  Lorenz  spica  is 
applied  and  the  patient  is  encouraged  to  walk  about.  This 
support  should  be  worn  for  from  six  months  to  a  year  in  order 
to  prevent  the  contractions  that  almost  inevitably  follow  opera- 
tions of  this  character.  Exercise  and  forcible  manipulation 
within  a  few  weeks  after  the  operation,  as  recommended  by  many 
writers,  are  not  only  of  no  service,  but  in  the  author's  experience 
harmful. 

AVhen  the  spica  is  removed  and  the  patient  is  allowed  to  run 
about,  motion  usually  returns.  At  this  time  massage  should  be 
employed  and  passive  movements  always  in  extension  and  abduc- 
tion. Later  gymnastic  training  is  of  great  value.  After  this 
operation,  provided  there  is  true  anatomical  cure,  motion  is 
usually  restricted  to  a  greater  or  less  degree,  and  in  older  sub- 
jects there  is  often  fibrous  anchylosis.  For  this  reason  it  should 
be  limited  to  unilateral  cases,  or,  at  all  events,  one  should  never 
operate  on  the  second  hip  until  the  result  of  the  operation 
in  the  first  is  known.  In  unilateral  cases  anchylosis  without 
deformity  is  not  a  serious  functional  disability,  as  there  is  solid 
support  without  shortening,  while  if  fair  motion  is  obtained,  as  in 
many  instances,  the  functional  result  is  far  better  than  after  simple 
transposition.  It  should  be  stated  that  even  after  the  open 
operation  this  transposition  is  often  the  outcome.  In  such 
cases  motion  is,  of  course,  free,  and  the  stability  is  somewhat 
greater  than  after  the  bloodless  operation.  If  after  this  operation 
motion  is  extremely  limited,  one  must  expect  flexion  and  adduction 
deformity  unless  it  be  prevented  by  careful  treatment.  In  certain 
instances  the  range  of  motion  may  be  increased  by  breaking  up 
adhesions  and  stretching  the  contracted  parts  under  anaesthesia. 


532 


ORTHOPEDIC  SURGERY. 


The  danger  of  the  operation  is  slight,  and  the  deaths,  with 
but  few  exceptions,  have  been  due  to  infection.  Lorenz  and 
Hoffa  lost  several  of  their  earlier  patients  from  this  cause,  but 
with  improved  technique  the  danger  is  slight.^  The  bad  results 
of  the  operation  may,  as  a  rule,  be  accounted  for  by  its  improper 


Fig.  318. 


Fig.  319. 


^ 


Unilateral  dislocation.  Two  years 
after  operation  in  1897  by  the  Lorenz 
method.     A  complete  cure. 


Unilateral  dislocation.  Eighteen  months  after 
operation  by  the  Lorenz  method  in  1897.  A  com- 
plete cure. 


performance,  particularly  the  failure  to  replace  the  femur  securely, 
or  by  failure  to  insure  asepsis,  or  by  inefficient  supervision  and 
after-treatment. 


1  Hoffa  has  performed  the  operation  248  times,  with  10  deaths,  8  due  to  the  operation,  the 
last  132  operations  without  a  death.  Lorenz,  in  260  operations,  lost  4  patients  from  septi- 
caemia.—Report  of  the  Thirteenth  International  Congress,  Paris,  August,  1900. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     533 

It  is  perhaps  unnecessary  to  state  that  operations  of  this  char- 
acter should  not  be  performed  unless  asepsis  can  be  assured, 
unless  the  operator  is  familiar  with  the  anatomy  of  the  parts, 
and  unless  the  essential  after-treatment  can  be  provided. 

Review  of  the  Treatment  of  Congenital  Dislocation  of  the  Hip. 
The  prospect  of  success  in  treatment  stands  in  direct  relation 
to  the  age  of  the  patient,  since  the  extent  of  the  pathological 


Fig.  320. 


Fig.  321. 


Unilateral  dislocation,  after  operation 
by  the  Lorenz  method  in  1897.  A  com- 
plete cure.    Compare  with  Fig.  293. 


Unilateral  dislocation,  two   years  after 
operation.    Compare  with  Fig.  294. 


changes  that  make  cure  difficult  or  impossible  depends  in  great 
degree,  as  in  acquired  dislocations,  upon  the  duration  of  the  dis- 
ability. Consequently  treatment  should  be  applied  as  soon  as 
the  displacement  is  discovered,  and,  as  has  been  stated,  there  is 
little  excuse  for  not  making  the  correct  diagnosis  when  the 
child  begins  to  walk.  The  treatment  of  selection  is  the  functional 
weighting  method  of  Lorenz.     By  this  means  a  larger  proportion 


534  OBTHOPEDIC  SUBGEBY. 

of  the  cases  may  be  cured,  and  in  all  instances  the  posterior  may 
be  changed  into  an  anterior  displacement,  which  is  a  great 
improvement. 

If  one  is  not  content  with  such  partial  success  the  treatment 
may  be  supplemented  by  arthrotomy,  and  if  anteversion  of  the 
upper  extremity  of  the  femur  prevents  success  it  may  be  remedied 
by  osteotomy. 

Excavation  of  the  acetabulum  will  often  assure  anatomical 
success. 

Anatomical  reposition  with  fair  or  even  very  limited  motion 
assures  better  function  in  unilateral  cases  than  transposition,  but 
anchylosis  with  deformity  is  certainly  no  improvement  on  the 
original  condition.  It  may  be  suggested,  also,  that  the  danger  of 
open  operation  even  if  slight  must  be  considered. 

In  the  treatment  of  adolescent  cases  one  should  attempt  to 
obtain  anterior  transposition  and  to  assure  it  by  fixing  the  limb 
for  a  sufficient  time  in  the  improved  position. 

As  has  been  stated,  the  operation  of  bloodless  reduction  had 
been  attempted  and  probably  successfully  performed  long  before 
the  time  of  Lorenz.  Its  first  advocate  was  Pravaz,  of  Lyons,  in 
1847;  and  Paci,  of  Pisa,  in  1887,  described  a  method  of  reduction 
resembling  in  some  respects  that  of  Lorenz,  but  far  less  definite 
and  effective,  in  that  primary  reduction  was  not  assured  nor  was 
the  Aveight  of  the  body  utilized  in  the  after-treatment.^ 

Palliative  Treatment.  Palliative  treatment  does  not  require 
extended  comment.  In  brief  in  unilateral  cases  a  cork  sole  may 
be  worn  to  equalize  the  length  of  the  limbs,  and  in  bilateral  cases 
a  corset  suitably  strengthened  with  steel  supports  may  be  adjusted 
if  the  lordosis  is  extreme.  Exercise  and  passive  manipulation 
with  the  aim  of  retaining,  as  far  as  possible,  the  ability  to  abduct 
and  to  extend  the  thighs  may  be  of  service  in  preventing 
secondary  contractions.  Overexertion  that  causes  discomfort 
or  pain  should  be  avoided. 

Congenital  Subluxation  of  the  Hip. 

As  has  been  stated,  there  are  cases  of  congenital  displacement 
of  the  hip  which  are  in  reality  subluxations.  In  such  cases  there 
is  a  slight  limp  and  slight  shortening,  and  an  X-ray  picture 
shows  a  secure  acetabulum  somewhat  above  the  .plane  of  the 
opposite   side.     These  subluxations  are  always  of   the  anterior 

i  Archiv.  di  Ortop.,  1892.  p.  420. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     535 

variety.     No  treatment  other  than  care  to  preserve  the  range  of 
abduction  is  required  as  a  rule. 

Snapping-  Hip. 

Some  individuals  possess  the  power  of  slightly  displacing  the 
hip,  usually  upon  the  superior  or  ujjper  border  of  the  acetabulum. 
This  is  sometimes  seen  in  infancy,  the  child's  thigh  snapping  with 
a  jar  or  even  audible  sound  upward  and  downward.  This  is 
usually  accomplished  when  the  child  is  seated  in  the  mother's 
lap,  the  thigh  being  flexed  and  adducted,  and  in  this  class  of 
cases  it  is,  according  to  the  mothers,  an  evidence  of  temper.  As 
the  displacement  may  be  increased  by  habit,  it  is  well  to  restrain 
it  by  applying  a  bandage  about  the  hip  and  to  prevent  flexion  of 
the  limb,  which  is  apparently  preliminary  to  its  accomplishment. 
(See  Snapping  Knee.) 

Coxa  Vara. 

Synonyms.  Depression  or  incurvation  of  the  neck  of  the 
femur  ;  bending  of  the  neck  of  the  femur. 

The  character  of  this  deformity  is  indicated  by  the  synonyms. 
The  term  coxa  vara  signifies  that  its  causes  and  effects  are 
similar  to  those  of  genu  valgum  and  varum,  the  more  common 
distortions  of  the  lower  extremities. 

Genu  valgum  and  varum  are  common  in  childhood,  but  rarely 
develop  in  adolescence.  Coxa  vara  is,  in  comparison,  an  infre- 
quent deformity,  and  it  is  peculiar  in  that  it  more  often  appears 
in  later  childhood  or  adolescence  than  at  the  earlier  period, 
doubtless  because  the  neck  of  the  femur  is,  at  the  age  when 
rhachitic  distortions  are  common,  very  short,  and,  therefore, 
relatively  stronger  than  the  shaft,  while  in  adolescence  the  con- 
ditions may  be  reversed. 

The  distortions  at  the  knee  are  self-evident,  but  the  neck  of 
the  femur  is  concealed  from  view ;  thus  the  diagnosis  of  coxa 
vara  may  be  somewhat  difficult  ;  and,  in  fact,  it  is  only  in  very 
recent  years  that  its  symptoms  have  been  recognized.  Fiorani^ 
first  described  the  deformity  as  it  had  been  observed  by  him  in 
children,  but  E.  Miiller^  first  called  attention  to  the  affection  as 
one  of  the  deformities  of  adolescence,  which,  until  that  time,  had 
been  mistaken  for  hip  disease. 

'  Gazetta  degli  Ospitale,  1881,  Nos.  16,  17. 
-  Beitrage  zur  klin.  Chir.,  1889,  Bd.  iv. 


536  OR THOPEDIC  S  UB  GEB  Y. 

Pathology.  The  term  coxa  vara  should  not  be  applied  to 
depression  of  the  neck  of  the  femur  that  may  be  secondary  to 
destructive  disease ;  for  example,  to  osteomyelitis,  arthritis 
deformans,  osteomalacia,  and  the  like,  but  it  should  be  reserved 
for  cases  of  simple  local  deformity.  In  most  instances  the 
deformity  affects  the  neck  as  a  whole  (cervical  coxa  vara)  ;  in 
others  it  is  most  marked  at  the  epiphyseal  junction  (epiphyseal 
coxa  vara).  Epiphyseal  coxa  vara  is  more  often  found  in  the 
adolescent  class,  and  particularly  in  those  cases  in  which  the 
symptoms  have  been  induced  or  aggravated  by  injury  or  strain. 

Fig.  322. 


Section  of  the  upper  extremity  of  a  normal  femur  at  eight  years  of  age  ;  angle  formed  by 
the  neck  with  the  shaft  140  degrees.  In  the  normal  subject  the  neck  of  the  femur  projects 
slightly  forward  (12  degrees)  and  upward  to  form  an  angle  with  the  shaft  of  about  125 
degrees.  In  childhood  this  angle  is  usually  somewhat  greater,  and  in  later  years  it  may  be 
somewhat  less  than  125  degrees ;  in  fact,  a  variation  between  110  and  140  degrees  may  be 
within  the  normal  limit. ' 

Whether  the  injury  caused  primarily  a  partial  epiphyseal  separa- 
tion which  afterward  slowly  increased  under  the  strain  of  func- 
tional use  or  suddenly  increased  a  pre-existing  distortion  of  the 
weakened  part  is  sometimes  difficult  to  decide.  A  number  of 
specimens  of  coxa  vara  have  been  examined,  but  no  changes, 
other  than  such  as  might  be  caused  by  the  deformity  itself,  have 
been  found.  These  are,  in  brief,  congestion  and  softening  of  the 
bone,  and  evidences  of  irritation  within  the  joint  during  the  pro- 
gressive stage  of  the  deformity,  and  the  general  adaptive  changes 

1  Humphrey.    Journ.  Anat.  Phys.,  vol.  xxiii.  p.  236. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     537 

in  all  the  components  of  the  joint  that  always  accompany  displace- 
ment or  distortion.  These  may  be  considerable,  including,  in 
advanced  cases,  a  change  in  the  acetabulum,  whose  upper  border 
is  less  sharply  defined  than  normal. 

Etiology.  Some  writers  assume  that  the  weakness  of  the  neck 
of  the  femur  that  predisposes  to  deformity  is  the  result  of  local  dis- 
ease, such  as  so-called  local  rickets  or  local  osteomalacia.  This  is, 
however,  simply  a  convenient  hypothesis.  Others  believe  the 
deformity  to  be  symptomatic  of  late  rickets,  although  evidence 
of  general  rhachitis  is  almost  never  present  in  the  ordinary  type 
as  it  appears  in  later  childhood  and  adolescence. 

Coxa  vara  may  be  classed  as  one  of  the  group  of  static  deformi- 
ties of  the  lower  extremity  caused  by  a  disproportion  between  the 
strength  of  the  supporting  structure  and  the  burden  that  is  put 
upon  it.  The  support  may  be  disproportionately  weak,  because 
of  inherited  delicacy  of  structure  ]  it  may  be  weakened  by  injury 
or  by  disease  ;  it  may  be  overburdened  by  weight  or  strain. 

Mechanical  Predisposition  to  Deformity.  In  many  cases  the  pre- 
disposition to  deformity  is  the  result  of  a  lessened  angle  of  the 
femoral  neck.  This  slight  and  predisposing  depression,  which 
appears  to  be,  in  many  instances,  the  effect  of  early  rhachitis, 
becomes  exaggerated  to  deformity  during  later  childhood  or 
adolescence.  In  this  sense — that  of  a  remote  result — coxa  vara 
might  be  classed  as  one  of  the  rhachitic  deformities.  The  impor- 
tance of  this  mechanical  factor  in  the  etiology  was  demonstrated 
to  me  by  the  investigation  of  a  number  of  cases  of  simple  frac- 
ture of  the  neck  of  the  femur  in  childhood.  In  these  cases  the 
neck  of  the  femur  was,  by  the  original  injury,  somewhat  depressed, 
and  although  complete  functional  recovery  followed,  yet  in  a 
number  of  the  cases  progressive  deformity,  attended  by  the 
symptoms  of  typical  coxa  vara,  resulted.  This  could  be  explained 
only  on  the  theory  that  the  lessened  angle,  subjecting  the  part  to 
greater  strain,  was  the  predisposing  cause  of  the  later  disability. 
Other  factors  in  the  etiology  may  be  general  weakness,  incident 
to  rapid  growth,  direct  injury,  and  the  strain  of  occupation.^ 

In  this  connection  it  may  be  stated  that  fracture  of  the  neck 
of  the  femur  in  childhood  may  cause  a  deformity  which  in  the 
absence  of  a  history  could  not  be  distinguished  from  the  ordinary 
form  of  coxa  vara,  of  which,  in  fact,  it  is  the  traumatic  form. 

1  One  case  of  congenital  coxa  vara  has  been  reported  by  Kredel  (Central,  fur  Chir.,  1896, 
No.  42).  Depression  of  the  neck  of  the  femur  in  congenital  dislocation  of  the  hip  has  been 
mentioned  in  the  section  on  that  affection. 


538 


ORTHOPEDIC  SURGERY. 


(See  Fracture  of  the  Neck  o£  the  Femur  and  Epiphyseal  Sepa- 
ration.) 

Statistics.  The  deformity  is  far  more  often  unilateral  than 
bilateral,  and  more  than  three-fourths  of  the  cases  are  in  males. 
In  a  total  of  109  cases  collected  from  the  literature,  83  were  in 
males  and  26  in  females  ;  85  were  unilateral  and  24  were 
bilateral.  The  more  important  details  in  the  54  cases  that  have 
come  under  my  own  observation  are  presented  in  the  accompany- 
ing table. 


Direction 

60    . 
II 

tab 

■M.9 
a '3 

to 

No. 

Name. 

Date. 

13 

Sex    || 

Age. 

Dura- 
tion. 

of  the  dis- 
tortion 
forward 
or  back- 

bggs 
22e§ 

■2  Etts^ 

1    CO  °* 

j 

2>^ 

ward. 

<-*•" 

«!  " 

tnaJOM 

1 

Nelson 

Oct. 

1896 

F.    Right 

6  mos. 

Posterior 

y^ 

1/ 

i 

Yes 

2 

Van  Orden 

June, 

1896 

M. 

4 

1  year 

" 

H 

No 

3 

Clayton 

April 

1891 

F.      Left 

6 

4  mos. 

" 

Y^ 

" 

4 

Zeltermann 

Jan. 

1898 

M.   Right 

7 

6  mos. 

" 

% 

% 

Yes 

5 

Vitt 

Mar. 

1897 

'• 

Left 

7 

6    " 

1 

1 

" 

6 

Brunjes 

Dec. 

1901 

M. 

7 

5  yrs. 

1 

VA 

Yes 

7 

Weneck 

Mav, 

1902 

" 

" 

7 

2    " 

" 

% 

j| 

" 

8 

Tuit 

July, 

1899 

F. 

" 

^y- 

6  mos. 

" 

V2 

% 

" 

9 

Seeger 

Mar. 

1897 

" 

" 

8 

2  yrs. 

" 

1 

1 

No 

10 

Rose 

Jan. 

1888 

" 

D. 

8 

3    " 

" 

" 

11 

Cohen 

June, 

1S98 

M. 

Right 

8 

6  mos. 

" 

% 

% 

Yes 

12 

Kebesky 

Aug. 

1900 

" 

Left 

8 

6    " 

Downw'd 

% 

" 

13 

Dengher 

July, 

1900 

" 

Right 

8 

lyear 

" 

% 

" 

14 

Hirsch 

Mar. 

1897 

" 

Both 

9 

2  yrs. 

Anterior 

" 

15 

Sussman 

Aug. 

1902 

F. 

Left 

10 

1  year 

Posterior 

'ii 

'ii 

" 

16 

Reardon 

Mar. 

1898 

M. 

Both 

11 

6    " 

Anterior 

" 

17 

Beckmyer 

Mar. 

1895 

" 

" 

11 

8    '• 

Posterior 

" 

18 

Brill 

Mar. 

1894 

" 

Right 

11 

lyear 

" 

i" 

i" 

No 

19 

Greer 

Jan. 

1896 

" 

Left 

12 

8  yrs. 

" 

1 

1 

Yes 

20 

Thomas 

Mar. 

1898 

F. 

Both 

12 

1  year 

Anterior 

R.3^ 

% 

" 

21 

Buechler 

Nov. 

1902 

M 

" 

12 

10  yrs. 

Downw'd 

Yes 

22 

Abrams 

Mar. 

1898 

F. 

Right 

13 

10  yrs. 

Posterior 

2" 

2M 

No 

23 

Rutschmann 

July, 

1896 

M. 

" 

13 

6  mos. 

" 

y^ 

/2 

" 

24 

Fraad 

Nov. 

1894 

" 

" 

13 

1  year 

" 

Vi 

K 

" 

25 

Shandley 

Dec. 

1898 

F. 

" 

13 

1    " 

" 

% 

IJ^ 

26 

Skidmore 

Nov. 

1899 

M. 

Left 

13 

3  yrs. 

" 

% 

IK 

27 

Cords 

May, 

1900 

Right 

14 

3  mos. 

" 

>l 

1^ 

Yes 

28 

Cunningham 

May, 

1897 

F. 

Left 

14 

1  year 

" 

^ 

13^ 

No 

29 

O'Neil 

Jan. 

1902 

" 

14 

lyear 

" 

% 

1^ 

No 

30 

Herbert 

April 

,1897 

M. 

Right 

14 

6  mos. 

" 

1 

1 

" 

31 

Bruning 

Oct. 

1897 

" 

" 

15 

2     " 

" 

% 

1 

" 

32 

Betz 

June 

1892 

" 

" 

15 

lyear 

" 

v^ 

3 

" 

33 

Lawson 

Oct. 

1897 

" 

" 

15 

1    " 

" 

1'^ 

" 

34 

Jensen 

Jan. 

1902 

F. 

Left 

15 

2    " 

" 

>2 

% 

" 

35 

McHenry 

July, 

1902 

M. 

Right 

15 

8K" 

Posterior 

y% 

% 

36 

Rose 

Jan. 

1896 

" 

Left 

15 

14  mos. 

" 

% 

¥4. 

" 

37 

Allen 

April 

,1897 

" 

" 

16 

Imo. 

" 

1 

^K 

" 

38 

Puckhaber 

June 

1893 

" 

Both 

16 

8  mos. 

" 

Yes 

39 

Gieger 

May, 

1900 

" 

Left 

16 

6    " 

" 

y-. 

I'i 

No 

40 

Schade 

July, 

1898 

" 

" 

16 

18    " 

" 

1 

1 

41 

Redfleld 

May, 

1901 

" 

Both 

16 

2  yrs. 

" 

" 

42 

Laherty 

July, 

1901 

" 

Left 

16 

7  mos. 

" 

y-i 

y 

" 

43 

Mortimer 

Nov. 

1901 

F. 

" 

16 

12  yrs. 

Downw'd 

y^ 

y 

44 

McHenry 

Jan. 

1902 

M. 

Both 

16 

2    " 

" 

No 

45 

Morris 

Jan. 

1900 

" 

Right 

17- 

6    " 

Posterior 

^i 

U 

No 

46 

Jocker 

Dec. 

1899 

'• 

Left 

17 

1  mo. 

" 

% 

y 

" 

47 

Beck 

July, 

1898 

F. 

Right 

17 

lyear 

" 

13I 

^y 

" 

48 

Zimmermann 

Oct. 

1896 

M. 

" 

17 

13  mos. 

" 

^ 

2K 

" 

49 

Healey 

Dec. 

1900 

M. 

Left 

17 

8    " 

" 

^A- 

-«i 

" 

50 

Fessner 

Mar. 

1894 

" 

17 

6     " 

" 

M 

H 

'■■ 

51 

Enderlich 

Jan. 

1897 

F. 

Right 

22 

lyear 

" 

% 

1 

" 

52 

Adult 
Hogan 

Mar. 
July, 

1896 
1901 

M. 
F. 

Right 

36 
20 

w 

1 

1 

<< 

53 

7  yrs. 

" 

54 

Hayem 

Oct. 

1901 

M. 

Both 

52 

30    " 

CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     539 

The  points  of  special  interest  in  these  and  four  other  cases 
more  recently  observed  may  be  summarized  as  follows  :  In  about 
one-third  of  the  cases  there  was  a  distinct  history  of  rhachitis 
in  infancy.  The  ages  at  which  the  symptoms  became  noticeable 
appeared  to  be  as  follows  : 

Adolescents,  twelve  to  seventeen 31 

Later  childhood,  five  to  eleven 17 

Early  childhood,  less  than  five 9 

Unknown        .......  1 

Total 58 

Forty-one  of  the  patients  were  males,  17  were  females.  In  47 
cases  the  deformity  was  unilateral,  25  of  the  right  and  22  of  the 
left  side  ;  in  11  it  was  bilateral.  In  53  cases  the  neck  of  the 
femur  was  distorted  in  a  direction  backward  and  downward  ;  in 
3  directly  downward  ;  in  4  forward  and  downward.  In  each 
case  of  the  last  group  the  deformity  was  bilateral.  Many  of  the 
cases  were  observed  before  the  X-ray  was  available  for  diagnosis, 
but  it  is  estimated  that  in  about  one-fourth  of  the  adolescent  cases 
the  distortion  was  greatest  in  the  vicinity  of  the  head  of  the  bone 
(epiphyseal  coxa  vara) ;  in  the  others  the  neck  of  the  femur  as  a 
whole  was  involved. 

Symptoms.  1.  Mechanical  Effects,  The  character  of  the 
symptoms  may  be  explained  by  a  description  of  the  distortion  and 
of  its  direct  effects  upon  the  function  of  the  joint.  When  the 
neck  of  the  femur  is  depressed,  for  example,  to  a  right  angle  with 
the  shaft,  the  trochanter  is  elevated  to  a  corresponding  degree 
above  N^laton's  line,  and  forms  a  noticeable  projection  as  con- 
trasted with  the  normal  contour  (Fig.  326),  a  projection  that 
becomes  more  marked  when  the  thigh  is  flexed  and  adducted 
(Fig.  325).  In  most  instances  the  neck  is  displaced  backward 
as  well  as  downward,  following  the  line  of  least  resistance,  and 
as  the  head  of  the  bone  remains  in  the  acetabulum  the  trochanter 
is  thrown  forward  and  the  limb  is  rotated  outward.  The  ability 
to  abduct  the  thigh  is  dependent  upon  the  length  and  upon  the 
upward  inclination  of  the  femoral  neck  (Fig.  178)  ;  when,  there- 
fore, this  inclination  is  diminished  the  range  of  abduction  is 
lessened,  in  part  by  the  greater  tension  that  is  exerted  upon  the 
lower  portion  of  the  capsule,  in  part  by  the  direct  contact  of  the 
rim  of  the  acetabulum  with  the  neck  and  trochanter  (Fig.  323), 
and  in  part  by  the  adaptive  contractions  that  always  accompany 
displacements  of  this  character.  It  is  evident,  also,  that  the  dis- 
tortion of  the  neck  backward  and  downward  changes  the  relation 


540 


ORTHOPEDIC  SUBOEBY. 


of  the  acetabulum  to  the  head  of  the  femur,  so  that  abduction  or 
flexion  tends  to  displace  it  from  its  socket.  Thus  the  range  of 
abduction,  of  inward  rotation,  and  of  flexion  is  limited,  while 
that  of  adduction,  outward  rotation,  and  extension  may  be 
increased. 

There  is  actual  shortening  of  the  limb  dependent  upon  the 
upward  displacement  of  the  shaft  of  the  femur.  This  is  not 
often  more  than  an  inch  in  the  ordinary  type  of  adolescent 
deformity,  but  the  apparent  shortening,  caused  by  the  adduction 
and  the  accommodative  upward  tilting  of  the  pelvis,  may  be 
extreme  ;  from  two  to  three  inches  is  not  uncommon  (Fig.  326). 


Fig.  323. 


skiagram  of  coxa  vara ;  deformity  most  marked  at  the  epiphyseal  junction.  This  illus- 
trates the  mechanical  limitation  of  ahduction  caused  by  the  deformity,  and  the  compensa- 
tory tilting  of  the  pelvis.    The  patient  is  shown  in  Fig.  326. 


2.  Physical  Effects.  The  symptoms  of  coxa  vara  of  the  ordinary 
form  are  :  discomfort,  aivkwardness,  limp,  shortening,  atrophy, 
limitation  of  motion,  deformity. 

Coxa  vara  is  a  more  disabling  deformity  than  genu  varum  or 
valgum,  and  its  attendant  symptoms  of  discomfort,  weakness, 
and  pain  are,  as  a  rule,  more  marked.  This  is  explained  by  the 
fact  that  in  coxa  vara  the  head  of  the  bone  is  in  part  displaced 
from  the  acetabulum  (Fig.  324),  while  in  the  deformities  at  the 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     541 

knee  the  joint  surfaces  remain  in  practically  normal  relation  to 
one  another. 

The  symptoms  of  unilateral  coxa  vara  vary  with  the  degree 
and  with  the  duration  of  the  deformity.  The  patient  usually 
complains  of  sensations  of  stiffness  and  weakness,  referred  to 
the  thigh.  These  are  more  noticeable  on  changing  from  a  position 
of  rest  to  one  of  activity,  and  at  times,  particularly  after  over- 
exertion, there  may  be  actual  pain.  By  far  the  most  important 
symptom  and  the  one  that  almost  always  induces  the  patient  to 
seek  treatment  is  the  limp.      This  limp,  accompanied,  as  it  usually 

Fig.  324. 


Cross-section  of  the  pelvis  and  the  deformed  femur.    A  scheme  to  show  the  effect  of  the 
deformity  in  limiting  abduction  of  the  limb.    The  dotted  outline  shows  the  normal  relation. 


is,  by  outward  rotation  of  the  foot,  resembles  that  caused  by 
united  fracture  of  the  neck  of  the  femur.  On  physical  exami- 
nation the  actual  shortening,  explained  by  the  elevated  and 
prominent  trochanter  and  the  peculiar  unequal  limitation  of 
motion,  will  make  the  diagnosis  clear.  In  some  instances  there 
may  be  a  slight  degree  of  muscular  spasm,  and  there  is  usually 
some  atrophy  of  the  muscles  of  the  thigh. 

Bilateral  Coxa  Vara.  If  the  deformity  is  bilateral  its  effect 
upon  the  gait  and  attitude  is  more  marked.  The  gait  is 
extremely  awkward,  resembling  somewhat  that  of  knock-knees, 


542  OB THOPEDIC  SURGER  Y. 

for  the  limitation  of  abduction  forces  the  patient  to  sway  the 
body  from  side  to  side  in  order  that  the  legs  may  pass  one 
another,  and  if  the  deformity  is  extreme  the  limbs  may  be  crossed 
over  one  another,  so  that  locomotion  may  be  difficult.  In  the 
ordinary  form  of  bilateral  coxa  vara  the  femoral  neck  on  each 
side  is  disjjlaced  backward  as  well  as  downward,  and  as  the 
head  of  the  femur  remains  in  the  acetabulum  the  shaft  is  thrown 
forward,  so  that  the  trochanter  is  nearer  the  anterior  superior 
spine  than  is  normal.  This  displacement  of  the  support  lessens 
the  inclination  of  the  pelvis  and  lessens  the  normal  lumbar 
lordosis.  Bilateral  coxa  vara  is  not  infrequently  accompanied 
by  other  deformities,  as,  for  example,  knock-knee  or  flat-foot 
(Fig.  327). 

Other  Varieties  of  Coxa  Vara.  In  rare  instances  the  neck  of 
the  femur  may  be  depressed  directly  downward  or  even  down- 
Avard  and  forward.  In  the  latter  instance  the  effect  of  the 
deformity  upon  the  function  of  the  joint  is  somewhat  different 
from  that  of  the  ordinary  type.  Abduction  is  limited  as  in  the 
common  form,  but  inward  rotation  replaces  outward  rotation, 
and  extension  is  limited  in  place  of  flexion.  This  type  of 
deformity  is  almost  always  bilateral.  It  is  accompanied,  usually, 
by  slight  permanent  flexion  of  the  thighs ;  thus  the  lumbar 
lordosis  is  exaggerated  ;  whereas,  in  the  ordinary  form  it  is 
usually  lessened. 

This  description  applies  to  the  ordinary  types  of  the  deformity 
as  it  is  seen  in  later  childhood  and  in  adolescence.  It  undoubt- 
edly occurs  in  early  life,  but  it  is  masked  by  the  more  noticeable 
distortions  of  other  parts,  and  as  an  isolated  deformity  that 
demands  treatment  it  is  uncommon.  One  case  was  observed  by 
the  writer  in  a  rhachitic  child  two  and  one-half  years  of  age. 
The  symptoms,  though  slight,  were  typical,  and  the  diagnosis 
was  confirmed  by  a  Roentgen  picture.  In  other  cases  seen  in 
later  childhood,  the  history  of  more  or  less  discomfort  for  many 
years  seemed  to  indicate  that  the  deformity  was  caused  directly 
by  rhachitis. 

In  the  majority  of  cases  the  symptoms  begin  insidiously, 
although,  in  many  instances,  they  may  follow  injury  or  over- 
exertion. (See  Partial  Epiphyseal  Separation.)  If  the  affection 
begins  in  adolescence  and  is  untreated,  the  period  of  discomfort, 
during  which  the  depression  of  the  neck  may  be  assumed  to  be 
progressive,  is  from  two  to  four  years  ;  but  if  the  deformity 
appears  at  an  early  age,  the  symptoms,  though  remittent  in  char- 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     543 

acter,  may  continue  indefinitely.  When  the  resistance  of  the 
comjiressecl  bone  becomes  sufficient  to  insure  stability,  the  dis- 
comfort ceases  and  the  disability  becomes  less  marked,  as  nature 
accommodates  the  mechanism  to  the  new  conditions. 


Fig.  325. 


Fig.  326. 


Coxa  vara,  showing  the  prominent  trochanter. 


Illustrating  the  tilting  of 
the  pelvis  and  the  apparent 
shortening  of  the  limb  in 
unilateral  coxa  vara.  Actual 
shortening,  three-fourths  of 
an  inch  ;  apparent  shortening, 
two  and  a  half  inches.  The 
deformity  of  the  epiphyseal 
type  was  apparently  induced 
by  overexertion.  (See  skia- 
gram, Fig.  323.) 


Diagnosis.  In  most  instances  diagnosis  may  be  easily  made, 
and  yet  coxa  vara  is  very  often  mistaken  for  hip  disease  ;  in  fact, 
we  are  indebted  to  this  mistake  for  most  of  the  specimens  of  the 
deformity  that  have  been  described.  The  essential  differences 
between  the  two  are  as  follows  :     In  tuberculous  disease  of  the 


544 


ORTHOPEDIC  SURGERY. 


hip  the  motions  of  the  joint  are  limited  in  every  direction  by 
reflex  muscular  spasm,  and,  as  a  rule,  other  evidences  of  the 
character  of  the  disease  are  apparent.  Coxa  vara  is  a  simple 
deformity ;  reflex  muscular  spasm  is  absent,  except  during 
exacerbations  due  to  injury  or  overstrain,  and  movement  is  not 
limited  in  all  directions,  but  only  in  abduction,  flexion,  and 
inward  rotation  when  the  deformity  is  of  the  ordinary  type. 
Actual  shortening  is  a  late  symptom  of  hip  disease,  while  it  is 
present  from  the  very  onset  of  coxa  vara.  It  is  a  shortening 
explained  by  the  elevation  of  the  trochanter  above  Nelaton's  line. 


Fig.  327, 


Double  coxa  vara  of  advanced  degree,  showing  the  involuntary  crossing  of  the 
legs  in  flexion. 

while  such  elevation  in  hip  disease  is  a  sign  of  destruction,  either 
of  the  head  of  the  bone  or  of  a  part  of  the  acetabulum. 

The  deformity  might  be  readily  mistaken  for  congenital  dislo- 
cation of  the  hip,  particularly  of  the  anterior  variety,  but  this 
would  be  excluded  by  the  history,  since  coxa  vara  is  an  acquired 
deformity.  The  diagnosis  between  the  two  affections  may  be 
easily  made  on  the  physical  signs  alone.  In  congenital  disloca- 
tion, if  the  thigh  be  flexed  and  adducted  to  its  extreme  limit,  the 
head  and  neck  of  the  displaced  bone  can  be  distinguished  beneath 
the  distended  tissues  of  the  buttock.  In  coxa  vara  nothing  but 
the  prominent  trochanter  can  be   made  out  on  similar  manipula- 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     545 

tion,  while  the  abnormal  mobility,  characteristic  of  the  dislocation, 
is  absent.  There  is,  however,  a  form  of  anterior  dislocation  in 
which  the  head  of  the  femur  has  a  secure  support  beneath  the 
anterior  superior  spine  in  which  diagnosis  from  the  physical  signs 
alone  may  be  somewhat  more  difficult.  An  X-ray  picture  will 
always  make  the  distinction  clear,  however. 


Fig.  328. 


Fig.  329. 


Unilateral  coxa  vara,  showing  the  effect  of  slight 
depression  of  the  neck  of  the  left  femur  upon  the 
attitude.    (See  Fig.  329.) 

Treatment.  If  the  deformity 
were  discovered  in  the  early  stage, 
one  might  hope  to  check  its  progress 
by  a  change  in  the  surroundings  and 
occupation  of  the  patient.     Standing, 

.•■•  .  J^  .  *='       The  patient,  Fig.  328,  eight  months 

particularly    in    the    attitude    of    rest,    after  cuneiform  osteotomy.    An  abso- 

which  throws  additional  weight  upon  '^^l  Z!imZ  ^'  ''^^'*''  '^'^^'^'"' 
the  weakened  part,  should  be  avoided, 

and  work  of  any  kind  that  induces  the  familiar  symptoms  of 
strain  should  be  discontinued.     As  much  time  as  possible  should 

35 


546  ORTHOPEDIC  SURGERY. 

be  spent  in  the  open  air,  and  diet  and  proper  therapeutical  remedies 
should  be  employed  if  evidence  of  constitutional  weakness  or 
rhachitis  is  present. 

Locally  massage  of  the  limbs  and  joints  and  forcible  manipula- 
tion, with  the  aim  of  overcoming  as  much  of  the  restriction  of  the 
range  of  abduction  as  may  depend  upon  the  secondary  changes 
in  the  soft  parts,  should  be  employed,  reinforced  by  regular 
gymnastic  exercises,  with  the  object  of  improving  the  circulation, 
upon  which  the  repair  of  the  weakened  bone  depends. 

If  the  deformity  is  unilateral  temporary  support  may  be  em- 
ployed. A  perineal  crutch  (Fig.  226)  or,  if  the  circumstances 
of  the  patient  permit,  one  of  the  convalescent  hip  splints  that 
allows  motion  at  the  knee,  may  be  used  (Fig.  231).  With  sup- 
port during  the  time  of  greatest  strain — that  is,  when  continuous 
walking  or  standing  may  be  acquired — combined  with  proper 
exercises  and  massage,  the  weak  part  may  become  sufficiently 
strong  to  perform  its  function  in  a  year  or  more,  but  supervision 
will  be  necessary  for  a  much  longer  time. 

Operative  Treatment.  Forcible  Abduction.  In  certain  instances, 
particularly  those  cases  in  adolescence  in  which  the  symptoms 
have  advanced  rapidly,  it  may  be  inferred  that  the  bony  structure 
of  the  affected  neck  is  congested  and  softened.  One  may  attempt, 
therefore,  to  restore  the  angle  by  forcibly  abducting  the  thigh,  as 
in  the  treatment  of  fracture  or  epiphyseal  separation.  (See  page 
549.)  In  this  manoeuvre  the  head  is  fixed  by  the  lower  portion 
of  the  capsule,  and  the  deformed  neck  is  forced  against  the  upper 
border  of  the  acetabulum  as  illustrated  in  the  figures  (Fig.  331). 
If  the  normal  range  of  abduction  can  be  restored,  one  may  infer 
that  the  deformity  has  been  corrected.  The  limb  should  then  be 
fixed  by  a  plaster  spica  bandage  in  this  attitude  of  extreme  abduc- 
tion for  two  months,  or  until  a  time  when  consolidation  in  the  new 
position  is  apparently  complete. 

A  support  should  be  used  for  a  time,  and  the  usual  treatment 
by  massage  and  exercise  should  be  carried  out  during  the  period 
of  convalescence. 

Linear  Osteotomy.  The  simplest  and  most  efficient  means  of 
overcoming  the  adduction  in  older  subjects  is  linear  osteotomy  of 
the  shaft  of  the  femur  just  below  the  trochanter  minor.  This 
may  be  performed  by  the  subcutaneous  method,  as  in  the  correc- 
tion of  the  deformity  of  hip  disease.  When  the  bone  has  been 
divided  the  shaft  is  rotated  inward  until  the  foot  is  brought  to 
the  normal  attitude,  and  it  is  then  abducted  to  the  normal  limit ; 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA.     547 

in  this  attitude  a  plaster  spica  bandage  is  applied  reaching  from 
the  axilla  to  the  toes. 

If  the  deformity  is  bilateral  it  is  often  sufficient  to  operate  on 
the  limb  which  is  most  affected.  When  the  fracture  is  consolidated, 
massage,  exercises,  and  manipulation  are  employed,  as  has  been 
described.  It  may  be  assumed  that  the  increased  blood  supply 
necessitated  by  the  repair  of  the  injury  will  affect  favorably  the 
weakened  bone  as  well.  The  final  result  in  several  cases,  in  which 
the  operation  was  performed  by  the  writer,  was  very  satisfactory. 

Cuneiform  Osteotomy.  In  younger  patients  the  deformity  may 
be  remedied  by  removal  of  a  cuneiform  section  of  bone  from  the 
upper  extremity  of  the  shaft  at  the  level  of  the  trochanter  minor 
(Fig.  330).  In  childhood  the  neck  of  the  femur  is  short  and 
the  strain  to  which  it  is  likely  to  be  subjected  slight ;  thus  opera- 
tive treatment  may  be  indicated  as  a  prophylactic  measure.  In 
fact,  one  should  treat  this  deformity  at  the  hip  on  the  same 
principles  as  the  similar  distortions  at  the  knee.  Coxa  vara  can- 
not be  rectified  by  mechanical  treatment ;  therefore,  unless  it  is 
directly  contraindicated  operative  intervention  should  be  advised. 

In  the  technique  of  this  procedure  there  are  several  points  of 
importance.  First,  the  restriction  of  abduction,  of  ligamentous 
or  muscular  origin,  must  be  overcome  by  vigorous  stretching  and 
massage  of  the  shortened  tissues  before  the  operation  on  the  bone, 
otherwise  it  will  be  difficult  to  bring  the  two  fragments  into 
proper  apposition.  An  incision  is  made  from  a  point  about  one 
inch  below  the  apex  of  the  trochanter  directly  downward  about 
three  inches  in  length.  The  bone  is  thoroughly  exposed  by 
separating  the  periosteum  from  the  site  of  operation.  The  base 
of  the  wedge  should  be  about  three-quarters  of  an  inch  in  breadth, 
directly  opposite  the  trochanter  minor  ;  the  upper  section  should 
be  practically  at  a  right  angle  with  the  shaft,  the  lower  being 
more  oblique  (Fig.  330,  2).  The  cortical  substance  on  the  inner 
aspect  of  the  bone  should  not  be  divided,  but,  reinforced  by  the 
cartilaginous  trochanter  minor,  should  serve  as  a  hinge  on  which 
the  shaft  of  the  femur  is  gently  forced  outward,  until  the  opening 
is  closed  by  the  apposition  of  the  fragments  after  the  upper  seg- 
ment has  been  fixed  by  contact  with  the  margin  of  the  acetabulum 
(Fig.  330,  3)  ;  thus  the  continuity  of  the  bone  is  preserved.  The 
limb  is  then  fixed  in  the  attitude  of  extreme  abduction  by  means 
of  a  plaster  spica  bandage,  which  should  include  the  foot  also,  for 
about  eight  weeks,  or  until  the  union  is  firm.  When  the  limb  is 
brought  to  the  line  of  the  body  the  neck  of  the  femur  is  restored 


548 


ORTHOPEDIC  SURGERY. 


to  its  proper  position  (Fig.  330,  4-)-  This  mechanical  method  of 
apposing  the  fragments  is  far  more  effective  than  any  system  of 
suture,  and  if  the  operation  is  carefully  conducted  there  is  no 
danger  of  displacement.  In  ordinary  cases  of  this  class,  accord- 
ing to  the  writer's  experience,  the  cure  is  absolute,  both  as  to 
symptoms  and  to  function.  No  after-treatment  other  than  the 
support  of  a  short  Lorenz  spica  for  a  month  or  more  is  required. 
The  opportunity  for  treatment  of  coxa  vara  in  earliest  childhood 
is  rarely  offered.     It  is  usually  the  direct  result  of  rhachitis,  and 


Fig.  330. 


1.  The  normal  femur.  2.  Depression  of  the  neck  of  the  femur— coxa  vara.  A.  A  wedge  of 
bone  has  been  removed.  3.  Abduction  of  the  limb  first  fixes  the  upper  segment  by  contact 
with  the  rim  of  the  acetabulum,  then  closes  the  opening  in  the  bone.  4.  Replacement  of  the 
limb  after  union  is  completed  elevates  the  neck  to  its  former  position. 

in  the  early  stage  at  least  it  is  probably  accompanied  by  other 
rhachitic  distortions.  It  would  be  well,  therefore,  to  examine 
the  hip-joints  of  rhachitic  children,  especially  those  who  present 
the  deformity  of  genu  valgum  with  reference  to  this  distortion.^ 

Fracture  of  the  Neck  of  the  Femur. 

Traumatic  Coxa  Vara.     Fracture  of  the  neck  of  the  femur 
in  childhood,  although  until  recently  unrecognized,  is  by  no  means 


i  The  bibliography  of  the  subject,  to  the  extent  of  127  references,  may  be  found  in  an  article 
by  Wagner  in  the  Zeits.  f.  Orth.  Chir.,  1900,  B.  viii.  H.  2. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     549 

an  uncommon  accident,  since  twenty  cases  have  come  under  the 
writer's  observation  during  the  past  nine  years. 

Fracture  of  the  neck  of  the  femur  in  childhood,  however, 
differs  markedly  in  its  symptoms  and  in  its  effects  from  that  in 
later  life.  In  childhood  the  immediate  effects  of  the  injury  are 
far  less  disabling,  and  the  patient  is  often  able  to  walk  about 
within  a  few  days  after  the  accident,  from  which  it  may  be  in- 
ferred that  there  is,  in  many  instances,  a  bending  and  breaking 
of  the  neck  without  actual  separation  of  the  fragments.     During 

Fig.  331. 


1.  Fracture  of  the  neck  of  the  femur.  2.  Restoration  of  the  normal  angle  by  forcible 
abduction.  3.  The  limb  in  normal  position.  Figs.  4,  5,  and  6  illustrate  separation  of  the 
epiphysis  of  the  head  of  the  femur  treated  by  the  same  method. 


the  period  of  repair  the  limp  and  attendant  discomfort  are  usually 
mistaken  for  symptoms  of  hip  disease. 

The  diagnosis  is  usually  simple.  In  all  the  cases  there  is  a 
history  of  injury,  usually  a  fall  from  a  height,  which  confined  the 
patient  to  the  bed  for  several  days  or  weeks.  On  physical  exam- 
ination shortening  of  half  an  inch  to  an  inch  is  found,  explained 
by  the  corresponding  elevation  of  the  trochanter.  Motion  in  the 
joint  is  more  or  less  restrained  by  voluntary  and  involuntary  con- 
traction of  the  muscles,  })ut  this  restriction  is  much  more  marked 
in  flexion,  abduction,  and  inward   rotation  than  in  other  direc- 


550  OB THOPEDIC  S UB  OEB  Y. 

tions  ;  a  limitation  explained  by  the  nature  of  the  displacement, 
the  neck  of  the  bone  having  been  forced  downward  and  backward. 

The  immediate  effect  of  the  injury  is,  as  has  been  stated,  less 
marked  than  in  the  adult,  but  the  deformity  often  tends  to 
increase  in  later  years,  because  the  right-angled  relation  of  the 
neck  to  the  shaft  exposes  it  to  greater  strain.  In  a  number  of 
the  patients  examined  several  years  after  the  injury,  there  was 
an  increase  of  the  actual  shortening  combined  with  permanent 
adduction.  At  this  time  the  deformity  could  not  have  been  dis- 
tinguished, except  for  the  history,  from  the  ordinary  coxa  vara 
of  a  rather  extreme  degree. 

Treatment.  If  the  diagnosis  is  made  after  the  accident,  or 
before  consolidation  is  complete,  one  should  attempt  to  replace 
the  neck  in  its  proper  relation  with  the  shaft  in  order  that  subse- 
quent deformity  may  be  prevented.  This  may  be  accomplished 
by  forcing  the  limb  into  extreme  abduction,  and  in  this  position 
a  plaster  bandage,  reaching  from  the  axilla  to  the  toes,  should 
be  applied  (Fig.  331). 

After  consolidation  of  the  fracture  a  hip  splint  or  Lorenz  spica 
may  be  worn  for  several  months  or  until  complete  repair  has 
taken  place.  Massage  and  forcible  manipulation,  if  limitation  of 
motion  remains,  combined  with  the  avoidance  of  overstrain,  may 
prevent  the  increase  of  the  deformity.  Otherwise  the  neck  of 
the  femur  should  be  replaced  in  its  normal  position  by  the 
removal  of  a  sufficient  wedge  of  bone  from  the  base  of  the 
trochanter  as  described  under  the  treatment  of  simple  coxa  vara 
(Fig.  330). 

Traumatic  Separation  of  the  Epiphysis  of  the  Head  of  the  Femur. 
As  has  been  stated,  in  traumatic  depression  of  the  neck  of  the 
femur  the  fracture  is  usually  at  about  the  centre  of  the  neck, 
which  in  childhood  is  but  little  more  than  an  inch  in  length. 
In  exceptional  cases  the  head  of  the  femur  may  be  separated  at 
the  epiphyseal  line.  This  disjunction  is  more  likely  to  occur  in 
adolescence  and  particularly  in  subjects  suffering  from  coxa  vara 
in  the  early  stage.  Thus  sudden  disability,  following  slight 
injury,  in  an  adolescent  who  has  complained  of  discomfort  and 
limp  for  some  time  before,  and  who  presents  on  examination  the 
signs  of  depression  of  the  neck  of  the  femur,  would  suggest  this 
accident ;  but  the  exact  diagnosis  can  be  established  only  by  a 
Roentgen  picture  or  by  operation.^ 

1  Sprengel.    Archiv  f.  kliu.  Chir.,  1898,  B.  xlvii.,  S.  805.    Clarke,  Lancet,  October  27, 1900. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VARA.     551 

The  treatment  is  similar  to  that  of  fracture,  but  the  functional 
derangement  of  the  joint  is  likely  to  be  greater  for  the  reason  that 
the  articulating  surface  of  the  head  of  the  femur  is  involved.^ 

Partial  Epiphyseal  Separation  in  Adolescence.  As  has  been  sug- 
gested, slight  injury  may,  under  favoring  conditions,  rupture  the 
periosteum  and  the  cortical  substance  at  the  junction  of  the 
epiphysis  and  the  neck  of  the  femur,  and  under  the  influence  of 
use  the  head  of  the  bone  may  be  slowly  depressed,  the  final  result 
being  the  epiphyseal  type  of  coxa  vara  that  has  been  mentioned. 
The  symptoms  of  this  variety  of  deformity,  which  is  practically 
limited  to  adolescence,  resemble  those  of  the  ordinary  form, 
except  that  they  are  more  marked  and  more  disabling. 

In  other  cases  the  displacement  may  be  greater  or  practically 
complete,  in  which  case  the  disability  is  immediate,  although  the 
traumatism  was  apparently  very  slight. 

This  accident  under  these  conditions  practically  never  occurs 
in  healthy  children.  Particular  attention  is  called  to  this  point, 
as  the  two  classes  of  cases  are  usually  confounded,  traumatic 
depression  of  the  neck  of  the  femur  being  classed,  as  a  rule,  as 
epiphyseal  separation.^  The  treatment  has  been  described  in  the 
preceding  section. 

Fracture  of  the  Neck  of  the  Femur  in  Adult  Life.  The  treatment 
by  forcible  abduction  and  fixation  recommended  for  incomplete 
fracture  of  the  neck  of  the  femur  or  epiphyseal  separation  in 
childhood  applies  also  to  the  same  injury  in  older  subjects.  If 
the  separation  is  complete  the  patient,  under  anaesthesia,  is  placed 
upon  a  pelvic  support.  Counter-traction  is  provided  by  a  wide 
bandage  passed  between  the  thighs  about  the  pelvis  and  fastened 
to  the  head  of  the  table.  The  assistant  makes  traction  on  the 
limbs,  gradually  abducting  them.  When  the  limit  is  reached  on 
the  sound  side  the  limb  is  retained  in  this  position  to  serve  as  a 
model  for  the  other  and  to  aid  in  fixing  the  pelvis.  A  long 
plaster  spica  is  then  applied  in  this  attitude  of  extreme  abduction 
and  extension  over  the  knitted  drawer,  as  described  elsewhere. 
In  certain  instances,  particularly  in  older  subjects,  the  short 
Lorenz  spica  may  be  applied  instead. 

One  often  encounters  cases  in  which  the  disability  persists  after 
fracture  of  the  neck  of  the  femur — a  disability  due  in  great  part 
to  flexion  and  adduction  deformity.     Such  deformity  may  be,  in 

1  Whitman.     Medical  Record,  July  25,  1893 ;  Annals  of  Surgery,  June,  1897,  February, 
18«9,  and  November,  1902. 
'^  Hoffa.    Zeitschrift  f.  Orthop.  Chir.,  1903,  Band  xi.  Heft  3. 


552  OE  THOPEDIC  S  UB  GEB  Y. 

many  instances,  reduced  by  moderate  force.  If,  as  is  often  the 
case,  the  fracture  has  failed  to  unite,  the  upper  extremity  of  the 
femur  may  be  forced  forward  beneath  the  anterior  superior  spine 
and  the  limb  may  be  fixed  in  an  attitude  of  abduction  and 
extension  by  a  Lorenz  spica,  as  originally  suggested  by  Lorenz. 

Coxa  Valga. 

Coxa  valga  is  a  term  used  to  signify  an  abnormal  elevation  of 
the  neck  of  the  femur  in  its  relation  to  the  shaft,  in  contrast  to 
coxa  vara,  an  abnormal  depression.  This  deformity  is  sometimes 
observed  in  limbs  which  have  never  supported  weight.  It  is  a 
possible  result  of  injury  also.  It  is  of  no  importance  from  the 
orthopedic  standpoint. 


CHAPTER   XVI. 

DEFORMITIES  OF  THE  BONES  OF  THE  LOWER  EXTREMITY. 

Of  the  distortions  of  the  lower  extremity  bow-leg  and  knock- 
knee  are  by  far  the  most  common,  comprising  about  15  per  cent, 
of  the  total  cases  in  orthopedic  clinics.  Of  the  two  bow-leg  is 
the  more  frequent  in  all  tables  of  statistics,  and  it  is  probable 
that  the  proportion  of  bow-leg  to  knock-knee  is  much  larger  than 
would  appear  from  the  hospital  records  ;  for  genu  valgum  is 
generally  recognized  as  a  serious  deformity,  while  bow-leg  is 
known  to  be  of  little  consequence  except  from  the  aesthetic  stand- 
point, so  that  its  rectification  is  more  often  trusted  to  the  power 
of  nature. 

Both  deformities  appear  to  be  more  common  in  male  than  in 
female  children — a  fact  explained,  perhaps,  by  the  greater  weight 
and  the  greater  susceptibility  of  the  former.  But  here,  again, 
statistics  may  be  influenced  somewhat  by  the  fact  that  bow-legs 
are  considered  to  be  of  more  consequence  to  the  boy  than  to  the 
girl,  because  of  the  concealment  that  the  skirts  will  insure  if  the 
distortion  is  not  outgrown  in  childhood. 

Statistics.  The  relative  frequency  of  the  two  deformities 
may  be  indicated  by  the  statistics  of  the  Hospital  for  Ruptured 
and  Crippled  for  a  period  of  ten  years.  During  this  time  5441  cases 
were  recorded,  3452  cases  of  bow-legs  (63.4  per  cent.),  1989  of 
knock-knees  (37.6  per  cent.).  Of  the  3452  cases  of  bow-legs 
2030  were  in  males  (58.8  per  cent.),  and  1422  were  in  females 
(42.2  per  cent.).  The  1989  cases  of  knock-knees  were  more 
evenly  divided  between  the  sexes,  1024  being  in  males  (51.4  per 
cent.),  and  965  in  females  (48.6  per  cent.). 

It  will  be  noted  that  45  of  the  cases  of  genu  valgum  were 
in  patients  over  fourteen  years  of  age,  as  compared  with  34 
cases  of  adolescent  or  adult  bow-legs.  The  writer's  personal  expe- 
rience in  the  clinic  enables  him  to  state  that  a  large  proportion 
of  the  cases  of  genu  valgum  actually  developed  or  increased  to 
an  extent  demanding  treatment  during  adolescence,  while  most 
of  the  cases  of  bow-leg  deformity  in  patients  more  than  fourteen 


554  OB  THOPEDIG  S  UB  GEB  Y. 

years  of  age  had  existed  since  early  childhood  or  were  the  result 
of  injury  or  disease. 

Bow-legs. 

Year.       No.  cases.      Males.  Females.    Over  21.  Over  14. 

1 1899      400      236  164  0  5 

2 1898      406      255  151  0  2 

3 1897      467      268  199  4  1 

4 1896      356      200  156  0  1 

5 1895      336      200  136  2  1 

6 1894      310      170  140  1  2 

7 1893      262      157  105  3  3 

8 1892      306      189  117  1  2 

9 1891      303      174  129  1  1 

10 1890      306      181  125  1  3 


Year. 

1 1899 

2 1898 

3 1897 

4 1896 

5 1895 

6 1894 

7 1893 

8 1892 

9 1891 

10 1890 


3452 

2080 

1422 

13 

21 

NOCK-KNEES. 

No.  cases. 

Males 

Females. 

Over  21. 

Ovei 

202 

120 

82 

1 

4 

233 

135 

98 

0 

11 

222 

120 

102 

2 

5 

232 

101 

131 

0 

0 

210 

109 

101 

0 

2 

212 

86 

126 

0 

0 

162 

80 

82 

1 

2 

168 

89 

79 

8 

2 

189 

92 

97 

1 

2 

159 

92 

67 

3 

3 

1024      965      16      31 


The  Etiology  of  Genu  Valgum,  Genu  Varum,  and  of  Other 
Distortions  of  the  Bones  of  the  Lower  Extremity.  The 
common  predisposing  cause  of  simple  deformities  and  disabilities 
of  the  lower  extremities — in  other  words,  those  not  caused  by 
local  injury  or  local  disease — is  the  erect  posture,  when  for  any 
reason  the  bones  and  the  joints  are  unequal  to  the  strain  of 
locomotion  and  to  the  task  of  sustaining  the  weight  of  the  body. 

Time  of  Onset.  At  two  periods  of  life  the  deformities  under 
consideration  most  often  develop.  The  first  is  in  early  childhood, 
when  the  upright  posture  is  first  assumed  ;  the  second  is  in 
adolescence,  when  the  rapid  growth  and  other  changes  incident 
to  this  period  may  lessen  the  stability  of  the  supporting  structures, 
and  when  the  strain  of  laborious  occupation  may  be  added  to 
that  of  the  increasing  weight  of  the  body. 

The  deformities  of  adolescence  are,  however,  relatively  insig- 
nificant in  number  compared  with  those  of  early  childhood,  for  in 
childhood  inherited  weakness  or  weakness  that  is  the  direct 
result  of  malnutrition  at  once  develops  into  deformity  under  the 
strain  of  standing  and  walking.  Thus,  as  a  rule,  the  deformities 
under  consideration  first  attract  attention   soon  after  the  child 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     555 

begins  to  walk,  and  the  patients  are  usually  brought  for  treatment 
during  the  second  or  third  year  of  life.  If  the  deformities  are 
severe  the  body  usually  presents  the  evidences  of  general  rha- 
chitis  ;  in  other  instances  the  distortion  of  the  legs  is  almost 
the  only  sign  of  its  presence,  and  in  a  certain  number  there  may 
be  no  evidence  whatever  of  malnutrition  or  disease. 

Predisposition  to  Deformity.     It  is  not  always  easy  to  explain 
why  weak  legs  bend  in  one  way  rather  than  in  another.     In 

Fig.  332. 


Habitual  posture  as  a  factor  in  the  etiology  of  rhachitic  bow-leg. 

some  instances  it  is  probable  that  a  slight  degree  of  deformity  is 
present  before  the  child  begins  to  walk.  For  example,  a  slight 
outward  bowing  of  the  legs  is  said  to  be  common  in  early  infancy, 
and  the  use  of  heavy  diapers  might  favor  an  increase  of  the  dis- 
tortion. Knock-knee  may  be  induced,  apparently,  by  holding 
the  infant  on  the  arm  with  the  knees  pressed  against  the  chest, 
and  certain  cases  of  knock-knee  and  bow-leg  combined  appear 
to  be  caused  directly  by  this  manner  of  carrying  the  infant 
habitually  upon  one  arm. 


556  ORTHOPEDIC  SUBGEBY. 

The  legs  of  rliachitic  children,  who  have  never  walked,  are 
often  somew^iat  distorted,  and  in  many  instances  this  may  be 
explained  by  the  habitual  postures  (Fig.  332). 

A  moderate  degree  of  bow-leg  is  not  infrequently  seen  in 
vigorous  infants  who  stand  and  walk  at  an  early  age.  Aside 
from  the  determining  curve  in  the  bone  that  may  be  present 
before  the  child  begins  to  walk,  this  predisposition  toward  bow- 
leg may  be  explained,  perhaps,  by  the  fact  that  young  infants 
often  separate  the  feet  widely  in  walking,  and  the  swaying  of 
the  body  from  side  to  side  may  tend  to  bend  the  legs  outward. 
In  weaker  or  less  vigorous  children  a  slight  degree  of  knock- 
knee  is  not  uncommon,  induced  more  directly  by  weakness  or 
inactivity  of  the  muscles,  as  a  result  of  which  the  child  stands 
with  the  knees  somewhat  flexed  and  pressed  together,  while  the 
feet  are  separated  and  everted,  an  exaggeration  of  the  so-called 
attitude  of  rest. 

Bow-leg  is  not  uncommon  in  adult  life,  and  it  is  popularly 
associated  wutli  strength  and  activity.  Undoubtedly  the  attitudes 
of  activity  would  tend  to  induce  bow-leg  rather  than  knock- 
knee,  so  that  this  tradition  may  have  a  foundation  of  truth.  It 
is  said  to  be  common  among  those  who  ride  constantly,  and  it 
may  be  a  direct  result  of  injury  or  disease  of  the  knee-joint,  but 
it  may  be  stated  that  well-marked  bow-leg  in  an  adult  has  almost 
always  existed  since  childhood.  This  statement  cannot  be  made 
of  genu  valgum,  since  it  may  develop  or  increase  during  ado- 
lescence or  even  in  adult  life.  The  predisposing  cause  is  weak- 
ness or  overstrain,  and,  as  has  been  stated,  in  the  popular  mind 
the  deformity  is  characteristic  of  weakness. 

The  Attitude  of  Rest.  Genu  valgum  is  an  exaggeration  of 
what  is  known  as  the  attitude  of  rest  or  relaxation,  in  which  the 
weight  of  the  body  is  thrown  in  great  part  upon  the  ligaments  of 
the  three  joints  of  the  lower  extremity.  In  the  attitude  of  rest 
the  pelvis  is  tilted  forward,  the  femora  are  rotated  inward  upon 
the  tibiae,  and  the  feet  are  separated  and  everted,  so  that  the 
greatest  strain  falls  upon  the  inner  side  of  the  knees  and  of  the 
feet.  Thus,  what  is  known  as  flat-foot  is  often  combined  with 
knock-knee ;  knock-knee  may  cause  flat-foot,  but  more  often  the 
flat-foot  may  induce  knock-knee,  or  both  may  be  the  effect  of  the 
same  general  cause.  Genu  valgum,  in  the  slighter  degree  at 
least,  may  be  induced  directly  by  improper  attitudes,  but  the 
attitudes  are,  as  a  rule,  the  result  of  overwork  to  which  the 
mechanism  is  subjected  ;  thus  the  knock-knee  of  adolescence  is 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     557 

SO  common  among  the  bakers  of  Vienna  that  "  baker's  knee  "  is 
there  synonymous  with  genu  valgum. 

Genu  valgum  may  be  secondary  to  distortion  elsewhere.  For 
example,  compensatory  knock-knee  is  usually  combined  with 
extreme  adduction  of  the  thigh  ;  it  may  be  the  result  of  the 
inactivity  necessitated  by  the  treatment  of  hip  disease  ;  it  may 
be  a  direct  result  of  injury,  and  it  is  sometimes  an  accompaniment 
of  osteomyelitis  or  osteoperiostitis  of  the  tibia,  which  causes  an 
overgrowth  and  abnormal  lengthening  of  the  leg.  There  are, 
however,  exceptional  cases  which  would  not  be  classed  with  the 
ordinary  deformity. 

The  Outgrowth  of  Deformity.  In  considering  the  treatment  of 
the  simple  static  deformities  of  the  lower  extremity  which  are 
usually  the  result  of  a  temporary  weakness  of  structure,  one  must 
first  answer  the  question,  "Will  not  the  child  outgrow  it?" 
This  belief  in  the  spontaneous  cure  of  deformity  is  very  strong, 
not  only  among  the  laity,  but  among  physicians  as  well  ;  and  it 
rests  upon  the  common  observation  that  crooked  legs  become 
straight,  or  at  least  less  deformed,  with  the  growth  of  the  child. 
In  fact,  if  one  were  to  judge  from  the  general  observation  of  the 
effect  of  growth  upon  the  deformities  of  this  class,  or  even  from 
the  tracings  of  the  legs  of  rhachitic  children  taken  from  year  to 
year,  one  might  conclude  that  all  deformities  of  this  class  might 
be  safely  left  to  themselves.  As  an  illustration  of  positive  evi- 
dence on  the  subject,  the  observations  of  Kamps^  on  32  cases  of 
rhachitic  distortion  of  the  lower  extremity  may  be  cited.  Four 
and  one-half  years  after  the  cases  were  first  seen  and  recorded 
examination  showed  that  75  per  cent,  were  cured,  15.3  per  cent, 
improved,  while  9.7  per  cent,  were  unimproved.  His  conclu- 
sions are  that  such  deformities  do  not,  as  a  rule,  require  special 
treatment  in  early  childhood,  but  that  after  the  age  of  six  years 
the  prognosis  for  spontaneous  cure  is  unfavorable. 

Veit^  photographed  a  number  of  rhachitic  children  seen  in  the 
surgical  clinic  of  the  University  of  Berlin,  and  after  a  lapse  of 
two  or  three  years  made  another  series  of  photographs  of  the 
same  patients,  who  had  meanwhile  received  no  treatment.  His 
conclusions  are  similar  to  those  of  Kamps,  namely,  that  surgical 
treatment  is  not  required  for  deformity  of  this  character  in  chil- 
dren less  than  six  years  of  age.  In  two  classes  of  cases,  however, 
the  prognosis  for  spontaneous  cure    is  not    favorable,  those  in 

1  Beitriige  zur  klin.  Chir.,  B.  xiv.  U.  1. 

2  Archiv  f.  klin  Chir.,  B.  1.,  S.  130. 


558 


ORTHOPEDIC  SUBGEBY. 


\ 


which  the  growth  has  been  checked  by  the  rhachitic  process,  and 
in  certain  cases  of  extreme  bow-legs,  "■  O  "  legs  (Fig.  333). 

The  rectifying  force  of  nature  acts  in  two  ways.  Assuming 
that  the  deformity  reached  its  limit  during  the  period  of  original 
weakness,  it  must,  of  course,  become  relatively  less  as  the  body 
increases  in  length  and  size.  In  fact,  the  outgrowth  of  deformity 
has  a  direct  relation  to  the  rapidity  of  growth  during  the  early 
years  of  childhood.  The  second  manifestation  of  the  power  of 
nature  is  more  positive.      It  may  be  assumed  that  when   the 

deformity  is  progressive  all  the 
tissues  are  affected  by  the  weak- 
ness ;  consequently  the  attitudes 
of  the  child  are  those  that  can 
be  most  easily  assumed  under 
the  abnormal  conditions.  But 
when  the  primary  cause  of  the 
weakness,  in  most  instances 
rhachitis,  is  no  longer  opera- 
tive, the  muscles  take  on  new 
activity  and  vigor,  and  the  ac- 
tions and  attitudes,  in  spite  of 
the  deformity,  become  approxi- 
mately normal.  Then,  accord- 
ing to  Wolff's  law  of  transfor- 
mation, the  internal  structure 
of  the  affected  bones  begins  to 
chansre  to  accommodate  itself  to 
the  new  conditions  of  weight 
and  strain  induced  by  the 
change  in  action  and  attitude  ; 
and  to  this  rearrangement  of  the  internal  structure  the  external 
shape  of  the  bones  must  conform  in  a  gradual  growth  toward  the 
normal  contour. 

On  this  theory  it  is  easily  explained  how  the  natural  outdoor 
life  of  the  country  has  long  been  celebrated  as  an  effective  treat- 
ment for  this  class  of  deformity.  But  it  by  no  means  follows 
that  deformity  is  always  outgrown  even  under  favorable  condi- 
tions. Improper  attitudes  that  favor  and  cause  deformity  are 
often  observed  among  those  who  are  free  from  weakness  and 
disability  and  from  the  influences  of  unfavorable  surroundings  ; 
and  such  attitudes  are,  of  course,  more  likely  to  persist  in  those 
who  were  once  obliged  to  assume  them  because  of  weakness  and 


A  type  of  deformity  in  whicli  the  prognosis 
as  regards  outgrowth  is  bad. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     559 

deformity.  Again,  the  weakness  of  structure  or  function  may 
be  an  inherited  peculiarity,  or  it  may  be  induced  by  disease  or 
by  improper  surroundings,  influences  that  may  continue  for  many 
years  and  thus  serve  to  check  the  natural  tendency  toward  cure. 
The  observations  on  the  outgrowth  of  deformity  have  been 
confined,  as  a  rule,  to  the  period  of  childhood,  and  most  often 

Fig.  334. 


Extreme  deformities,  the  result  of  infantile  rhachitis.    The  left  leg  forms  practically 
a  right  angle  with  the  thigh.    (See  Fig.  338.) 


they  have  been  made  with  reference  to  the  more  serious  grades 
of  distortion,  which  are  the  direct  result  of  rhachitis. 

It  mu.st  be  borne  in  mind,  however,  that  the  true  significance 
of  these  deformities  in  the  adult  must  be  judged  from  the 
aesthetic  rather  than  from  the  medical  point  of  view,  and 
although  the  extreme  degrees  of  bow-leg  and  knock-knee  are 
relatively  rare,  yet  in  the  minor  grade  both  deformities  are  very 


560  ORTHOPEDIC  SURGERY. 

common  in  adult  males  and  in  all  probability  in  adult  females 
also. 

In  1887  the  writer^  noted,  among  2000  adult  males  observed 
on  the  streets  of  Boston,  400  cases  of  bow-leg  and  32  cases  of 
knock-knee.  One  may  assume,  then,  that  the  legs  of  about  one 
adult  male  in  five  deviate  more  or  less  from  the  line  of  sym- 
metry— a  conclusion  that  has  been  confirmed  by  many  subsequent 
observations.  It  may  be  admitted  that  a  certain  number  of  the 
distortions  under  consideration  are  acquired  during  adolescence, 
but  it  is  probable  that  the  greater  number  of  those  that  may  be 
noted  in  walkers  upon  the  streets  represent  the  incomplete  out- 
growth of  a  deformity  of  childhood. 

The  statement  is  often  made  that  these  distortions  of  the  legs 
are  common  in  childhood,  but  rare  in  adult  life.  Just  what  the 
proportion  may  be  in  childhood  it  is  impossible  to  say,  but  it  is 
not  likely  to  be  greater  than  one  in  five.  One  must  conclude 
that  statistics,  on  which  such  statements  are  based,  have  been 
made  up  from  the  records  of  hospitals  where  it  is  extremely 
uncommon  for  an  adult  to  apply  for  the  treatment  of  bow-leg,  to 
which  he  has  become  accustomed  since  childhood,  unless  the 
deformity  is  extreme  or  is  attended  by  pain. 

Granting  that  the  power  of  nature  is  quite  sufficient  to  modify 
or  to  cure  even  the  more  extreme  distortions  of  childhood,  still 
it  is  evident  that  this  natural  force  is  often  ineffective  in  com- 
pleting the  cure.  Therefore,  in  doubtful  cases  at  least,  one  should 
lend  assistance  in  that  class  of  patients  likely  to  appreciate  the 
advantage  of  symmetry  over  deformity,  even  though  it  be  unat- 
tended by  discomfort  or  disability. 

Genu  Valgum. 

Synonyms.     Knock-knee,  in-knee. 

In  the  erect  posture  the  thighs,  whose  upper  extremities  are 
separated  by  the  pelvis  and  by  the  projecting  femoral  necks, 
incline  slightly  inward  to  the  knees,  forming  an  angle  at  the 
knee,  opening  outward,  of  about  172  degrees.  This  angle  varies 
with  the  breadth  of  the  pelvis,  and  it  is,  therefore,  less  in  adult 
females  than  in  males  (Figs.  335  and  336).  The  internal  condyle 
of  the  femur  is  slightly  longer  than  the  external ;  thus  the  inclina- 
tion of  the  femur  is  compensated  and  the  plane  of  the  knee-joint 
is  horizontal. 

1  New  York  Medical  Record,  July  30, 1887. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     561 

When  the  inward  projection  of  the  knees  is  increased  to  a 
noticeable  degree  the  tibiae  are  no  longer  perpendicular ;  their 
upper  extremities  incline  inward  so  that  in  the  erect  posture 
the  feet  are  separated  when  the  knees  are  in  contact  (Fig.  337). 
In  the  slighter  grades  of  knock-knee,  which  are  due  in  great 
degree  to  laxity  of  the  ligaments,  the  deformity  is  apparent  only 
when  the  weight  of  the  body  is  borne,  but  in  more  marked  cases, 
although  the  distortion  is  increased  by  the  weight  of  the  body, 
it  cannot  be  overcome  when  this  is  removed,  because  it  depends 
upon  actual  changes  in  the  shape  of  the  bones  themselves. 

As  has  been  stated,  the  normal  inward  inclination  of  the  femur 
is  compensated  by  the  greater  length  of  the  internal  condyle,  and 


Fig.  335. 


Fig.  336. 


Female.  Male. 

The  normal  inclination  of  the  femora.    (PfeiflFer.) 


in  the  deformity  of  knock-knee  the  plane  of  the  knee-joint  is 
still  preserved  by  an  apparent  elongation  of  the  inner  condyle. 
Formerly  it  was  supposed  that  there  was  an  actual  overgrowth 
of  this  part  of  the  epiphysis,  which  caused  the  deformity,  but  the 
observations  of  Mikulicz  and  Macewen  have  shown  that  this 
apparent  lengthening  is  in  reality  due  in  great  part  to  a  deformity 
of  the  lower  extremity  of  the  shaft  of  the  femur,  which  is  so  bent 
that  the  epiphyseal  line  has  an  increased  obliquity.  And  the 
hypothesis  that  bone  grows  more  rapidly  when  relieved  from 
weight  and  strain  has  })een  disproved  by  Wolff,  who  has  demon- 
strated that  changes  in  the  bones  are  the  result  of  accommodation 
to  altered  function  and  attitude.    (See  page  235.)    The  deformity 

36 


562 


OB  THOPEDIC  S  UR  GEB  Y. 


is  not  limited  to  the  femur  ;  in  most  instances  there  is  a  similar, 
although  usually  slighter,  irregularity  in  the  epiphyseal  line  of 
the  upper  extremity  of  the  tibia,  the  shaft  being  so  bent  that 
when  it  is  placed  in  the  perpendicular  position  its  internal  con- 
dylar surface  is  higher  than  the  external.  In  some  instances  the 
primary  and  principal  deformity  is  of  the  tibia,  the  distortion 
being  most  marked  in  its  upper  third  (Fig.  337). 


Fig.  337. 


Adolescent  knock-knees.    Deformity  most  marked  in  the  tibite.    (See  Fig.  340.) 


Changed  Relation  of  the  Femur  and  Tibia.  In  addition  to  the 
direct  deformities  of  the  bones  there  is  a  change  in  the  relation 
of  the  femur  to  the  tibia.  The  former  is  rotated  inward  and  the 
latter  is  rotated  outward.  In  some  instances  there  is  also  a  cer- 
tain degree  of  overextension  at  the  knee.  This  is  more  often 
observed  in  the  adolescent  type,  in  which  there  is  laxity  of  the 
ligaments  (Fig.  337).  In  the  ordinary  form  of  rhachitic  knock- 
kuee  in  childhood  the  habitual  attitude  is  one  'of  slight  flexion 


JDEFOJRMITIES  OF  BONES  OF  LOWER  EXTREMITY.     563 

at  the  knees,  and  in  extreme  cases  there  may  be  actual  limitation 
of  the  range  of  extension  at  the  knee,  and  at  the  hip  as  well. 

The  Accommodative  Attitude.  When  the  limb  is  fully  extended 
the  deformity  is  most  marked,  because  the  shortened  ligaments 
and  tissues  on  the  outer  aspect  of  the  joint  become  tense,  and 
because  the  outward  rotation  of  the  tibia  is  increased.  As  the 
leg  is  flexed  the  deformity  lessens,  and  in  the  attitude  of  complete 

Fig.  338. 


Skiagram  of  Fig.  334,  sliowing  the  deformity  to  be  due  to  distortions  of  the  diaphyses 
of  the  bones,  while  the  epiphyses  are  practically  normal. 


flexion  it  disappears  (Fig.  340).  This  is  explained  by  the  fact 
that  the  posterior  surface  of  the  condyles  is  not  affected  by  the 
deformity  of  the  shaft,  while  the  relaxation  of  the  ligaments  and 
the  outward  rotation  of  the  femora  allow  the  tibiae  to  become 
parallel  with  one  another.  This  accounts  for  the  habitual  atti- 
tude of  slight  flexion  which  is  so  often  assumed  by  patients  who 
thus  uuconsciou.sly  accommodate  themselves  to  the  deformity. 


664 


OBTHOPEDIC  SUBQEBY. 


Fig.  339. 


Secondary  Deformities.  The  outward  inclination  of  the  leg 
throws  more  weight  upon  the  inner  border  of  the  foot  and  tends 
to  depress  it  into  the  attitude  of  valgus.  Thus  knock -knee  in 
weak  children  is  often  accompanied  by  flat-foot,  but  in  the  more 

extreme  grades  of  deformity 
the  efforts  of  the  patient  to  com- 
pensate for  the  abnormal  sepa- 
ration of  the  feet  may  result  in 
habitual  supination  ;  in  fact, 
confirmed  and  extreme  knock- 
knee  in  older  subjects  is  usually 
accompanied  by  a  slight  degree 
of  varus  that  becomes  very  evi- 
dent after  the  correction  of  the 
deformity  by  operation.  Even 
in  the  mildest  type  of  knock- 
knee  this  compensatory  and 
conservative  effort  of  nature  is 
shown  by  the  so-called  pigeon- 
toed  walk,  which  is  often  the 
first  symptom  that  attracts  at- 
tention. 

Gait.  The  gait  of  the  patient 
with  well-marked  genu  valgum 
is  peculiarly  awkward  and 
shambling.  The  knees  "  in- 
terfere," and  must  be  assisted, 
as  it  were,  in  the  effort  to  pass 
one  another  in  walking.  In  the 
slighter  cases  the  thigh  is  ab- 
ducted and  rotated  outward  at 
the  moment  of  passing  its  fel- 
low, the  movement  being  then  reversed  as  it,  in  its  turn,  supports 
the  weight  ;  but  in  the  more  severe  type  this  voluntary  effort  of 
the  muscles  of  the  leg  is  not  sufficient,  and,  in  addition,  the  body 
is  swayed  from  side  to  side  and  the  legs  are  alternately  swung 
outward  and  lifted  around  one  another. 

The  deformity  and  the  effects  of  the  deformity  on  the  gait  and 
attitude  are  the  most  important  symptoms,  as  of  other  distortions 
of  similar  origin.  The  patient  is,  as  a  rule,  easily  fatigued,  and 
pain  during  the  progressive  stage,  referred  to  the  inner  side  of 
the  knee,  where  the  ligaments  are  subjected  to  continuous  strain. 


Deformity  of  the  femur  in  genu  valgum. 

(Mikulicz.) 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     565 

is  a  common  symptom,  particularly   in  the  adolescent  type  of 
genu  valgum. 

Unilateral  Knock-knee.  This  description  refers  particularly  to 
the  cases  in  which  the  deformity  is  bilateral.  Not  infrequently 
it  is  unilateral,  the  limb  being  so  shortened  by  the  distortion  that 
a  well-marked  limp  replaces  the  swaying  gait.  The  pelvis  is 
tilted  toward  the  short  limb,  while  the  body  is  inclined  in  the 
opposite  direction,  thus  in  cases  of  long  standing  a  permanent 
curvature  of  the  lumbar  spine  may  be  present. 


Fig.  340. 


Adolescent  knock-knee,  showing  the  disappearance  of  the  deformity  when  legs  are  flexed. 

(See  Fig.  337.) 

Knock-knee  Combined  with  Bow-leg  and  with  General  Rhachitic 
Distortions.  Occasionally  the  unilateral  knock-knee  may  be 
accompanied  by  an  outward  bowing  of  its  fellow  ;  and  in  the 
marked  distortions  of  the  lower  extremity,  induced  by  rhachitis, 
the  bones  may  be  twisted  and  bent  in  various  directions,  although 
the  outward  expression  of  the  deformity  may  be  genu  valgum. 
For  example,  the  femora  may  be  bent  forward  and  outward 
above  and  inward  and  backward  below,  while  the  tibise  may 
be  bent  inward  above  and  outward  and  forward  below. 

In  other  instances,  especially  in  the  slighter  rhachitic  deformi- 
ties, an  outward  bowing  of  the  leg  may  accompany  a  slight 
degree  of  kiiock-knee,  so  tliat  it  may  be  difficult  to  classify 
tlie  deformity. 


566 


ORTHOPEDIC  SURGERY. 


In  the  more  extreme  deformities  of  the  rhachitic  type  the 
shape  as  well  as  the  contour  of  the  bones  is  markedly  modified,  for 
example,  the  internal  border  of  the  tibia  may  become  very  prom- 
inent at  its  upper  extremity,  and  may  project  beneath  the  skin 
like  an  exostosis  (Fig.  341).  A  change  in  the  contour  of  the 
fibula  accompanies  and  corresponds  to  that  of  the  tibia,  although 


Fig.  341. 


Knock-knee  and  bow-leg. 

it  is,  as  a  rule,  much  less  pronounced.  As  has  been  stated,  the 
internal  structure  or  architecture  of  the  affected  bones  is  changed 
to  accommodate  the  new  static  conditions,  and  according  to 
Wolff  the  internal  change  precedes  the  external  deformity. 

Pathology.       In    knock-knee    due    directly   to   rhachitis   the 
changes  in  the  bones  and  in   the  epiphyseal  cartilages  are  char- 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     567 

acteristic  of  that  affection,  but  in  the  milder  grades  of  deformity, 
aside  from  the  change  in  the  contour  of  the  bones,  the  trans- 
formation of  the  internal  structure,  and  in  some  instances  slight 
thickening  or  irregularity  of  the  epiphyseal  cartilages,  there  is 
little  noteworthy  change  from  the  normal  (Fig.  339).  The 
tissues  on  the  internal  aspect  of  the  joint  are  relaxed  ;  those  on 
the  outer  side,  the  lateral  ligaments,  the  capsule  and  the  biceps 
muscle,  are  contracted  and  resist  the  reduction  of  the  deformity. 
In  the  interior  of  the  joint  slight  changes  in  the  articulating  sur- 
faces of  the  bones,  and  evidences  of  chronic  irritation  of  the 
synovial  membrane  have  been  described. 

Measurements.  There  are  various  methods  of  measuring  the 
deformity.  One  of  the  simplest  and  most  practical  is  to  trace 
the  outlines  on  paper,  while  the  child  is  seated  with  the  limbs 
fully  extended,  the  knees  being  sufficiently  separated  to  allow 
the  pencil  to  pass  between  them.  The  increase  of  the  deformity, 
depending  upon  the  laxity  of  the  ligaments  and  upon  the  outward 
rotation  of  the  tibiae,  may  be  estimated  by  measuring  the  distance 
between  the  two  internal  malleoli  when  the  patient  stands,  the 
knees  being  slightly  separated  as  before,  and  comparing  this 
measurement  with  that  between  the  similar  points  in  the  tracing. 

In  the  early  stage  of  progressive  knock-knee,  particularly  in 
the  type  not  caused  directly  by  rhachitis,  laxity  of  ligaments 
and  the  habitual  assumption  of  the  attitude  of  rest  will  account 
for  the  deformity,  which  the  patient  may  be  able  to  overcome,  in 
great  degree  at  least,  by  voluntary  effort.  This  voluntary  control 
of  the  deformity  is  very  suggestive,  as  indicating  certain  factors 
in  its  etiology,  and  the  principles  that  should  be  followed  in  its 
treatment. 

Treatment.  The  treatment  of  the  deformity  under  considera- 
tion may  be  classified  as  expectant,  mechanical,  and  operative. 

Expectant  treatment  should  not  be  expectant  in  the  sense  that 
nothing  is  to  be  done  to  correct  the  deformity,  but  expectant  in 
that  more  positive  treatment  by  braces  or  by  operation  is  delayed 
or  avoided  if  it  proves  to  be  unnecessary. 

During  this  period  the  predisposing  cause  of  the  deformity,  if 
it  is  constitutional,  should  receive  proper  dietetic  or  medicinal 
treatment,  as  already  described  in  the  chapter  on  Rhachitis. 
And,  if  possible,  the  direct  exciting  causes  of  the  deformity  must 
be  removed — that  is  to  say,  the  improper  attitudes,  or,  in  the 
adolescent,  the  predisposing  occnipations  should  be  discontinued. 
General  massage  of  the  limbs  may  be  employed  with  advantage  ; 


568 


ORTHOPEDIC  SURGERY. 


in  older  children  special  exercises  may  be  practised,  and  in  all 
cases,  whether  braces  are  used  or  not,  direct  manipulation  of  the 
distorted  limbs  is  of  the  first  importance. 

Manipulation.  The  limbs  should  be  vigorously  massaged  at 
morning  and  night,  and  forcibly  straightened.  The  latter  pro- 
cedure is  conducted  as  follows  :    The  patient  is  seated  in  a  chair, 


Fig.  34?. 


Fig.  343. 


The  Thomas  knock-knee  brace. 


Thomas  knock-knee  braces  with  pelvic  band.  The 
pelvic  band  may  be  divided  also,  the  two  parts  being 
joined  by  straps  (Fig.  344). 


the  limb  being  fully  extended  so  that  the  deformity  is  made  as 
extreme  as  possible.  One  hand  then  clasps  the  knee,  the  palm 
lying  against  its  inner  aspect  ;  with  the  other  the  calf  is  grasped 
firmly  and  the  leg  is  then  gently  straightened  over  the  fulcrum 
formed  by  the  palm  of  the  hand,  and  is  held  in  the  corrected 
position  for  a  moment.     This  manipulation  should  be  continued 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     569 

with  gradually  increasing  force,  although  not  to  the  extent  of  caus- 
ing actual  pain,  for  ten  minutes  at  least  twice  in  the  day  and 
oftener  if  possible. 

Posture  and  Exercise.  It  has  been  stated  that  genu  valgum  is 
often  accompanied,  especially  in  the  rhachitic  cases,  by  flat-foot, 
while  in  another  type  the  inversion  of  the  feet,  or  in  the  more 

Fig.  344. 


Modified  Ttiomas  ijnocli-lcnee  braces  applied. 


severe  cases  the  actual  fixed  attitude  of  varus,  indicates  the  effort 
of  nature  to  withstand  and  to  compensate  for  the  deformity  at 
the  knee.  This  serves  as  an  indication  for  making  the  soles  of 
the  shoes  thicker  on  the  inner  border,  as  in  the  treatment  of  flat- 
foot,  in  order  to  throw  the  strain  upon  the  outer  border  of  the 
foot.     The   patient  sliould  bo   instructed  to  walk  with  the  feet 


570  ORTHOPEDIC  S UB GEB  Y. 

parallel  with  one  another,  and  for  older  children  the  tip-toe  exer- 
cises, in  which  the  body  is  raised  upon  the  toes  as  many  times 
as  the  strength  permits,  or  games  or  exercises  in  which  the  legs 
are  extended  should  be  encouraged.  Such  exercises  are  often 
efficacious  in  the  early  stage  of  adolescent  knock-knee,  for,  as 
has  been  mentioned,  genu  valgum  is  an  exaggeration  of  the  atti- 
tude of  rest ;  therefore,  its  progress  should  be  checked  by  the 
assumption  of  the  attitudes  proper  to  activity.  Bicycle,  and 
particularly  horseback,  riding  may  be  recommended  also  in  this 
class  of  cases.  A  careful  record  of  the  deformity  should  be  kept 
during  this  tentative  treatment,  and  if  it  improves  somewhat  one 
is  justified  in  delaying  the  more  radical  measures.  This  question 
may  be  decided,  as  a  rule,  in  three  months  if  instructions  are 
faithfully  followed. 

Treatment  by  Braces.  The  most  efficient  brace  for  the  treatment 
of  genu  valgum  is  the  simple  straight  steel  bar  or  splint  extend- 
ing from  the  trochanter  to  the  heel  of  the  shoe,  without  joint  at 
the  knee.  The  greater  efficacy  of  the  rigid  bar  as  compared  with 
the  jointed  brace  is  explained  by  the  fact  that  the  rectifying 
force  acts  constantly  when  the  joint  is  fixed,  and  because,  in  many 
instances,  the  patient  habitually  flexes  the  knees  so  that  direct 
pressure  cannot  be  made  upon  the  deformity  by  a  brace  that 
allows  this  attitude. 

The  Thomas  Brace.  The  simplest  and  cheapest  brace  is 
that  of  Thomas,  which  consists  of  a  light  steel  bar  provided  with 
a  pad  at  its  upper  end  for  pressure  against  the  trochanter,  while 
the  lower,  rounded  extremity  is  turned  inward  at  a  right  angle, 
to  pass  through  the  heel  of  the  shoe.  The  knee  is  fixed  by  a 
posterior  bar  attached  to  a  thigh  and  calf  band,  as  illustrated  in 
the  figure.  When  the  brace  is  applied  the  knee  is  drawn  back- 
ward and  outward  and  is  attached  firmly  to  the  brace  by  a  roller 
bandage  (Fig.  342). 

In  the  more  extreme  cases  in  which  the  knees  and  thighs  are 
habitually  flexed,  the  addition  of  a  pelvic  band  attached  to  the 
uprights  by  a  free  joint  at  the  hips  adds  to  the  comfort  and 
efficiency  of  the  apparatus,  as  the  attitude  of  outward  or  inward 
rotation  can  be  regulated  by  twisting  the  uprights  slightly.  Or 
the  pelvic  band  may  be  divided  and  attached  by  means  of  straps 
on  the  front  and  back.  The  uprights  may  be  bent  somewhat 
inward  at  first,  and  as  the  legs  become  straighter  they  are 
straightened  and  finally  bent  slightly  outward  to  allow  for  the 
overcorrection  of  the  deformity  (Fig.  344).     Twice  a  day  the 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     571 


Pig.  345. 


braces  should  be  removed  to  allow  for  massage,  manipulatioD, 
and  for  voluntary  exercises  of  the  limbs.  In  most  cases  the 
braces  are  not  employed  at  night,  although  the  rectification  of 
the  deformity  may  be  hastened  by  their  constant  use. 

If  the  deformity  is  unilateral  so  that  a  brace  is  required  for  one 
limb  only,  the  other  shoe  should  be  raised  by  a  cork  sole  about 
three-quarters  of  an  inch  in  thick- 
ness, to  make  walking  easier. 
Children  soon  become  accustomed 
to  the  braces  and  walk  easily  in 
spite  of  the  absence  of  joints  at 
the  knees. 

Another  simple  and  efficient 
brace  is  that  used  at  the  Children's 
Hospital  at  Boston  (Fig.  345). 
The  upper  part  of  the  brace  is 
turned  backward  and  upward  to 
lie  against  the  buttock,  and  the 
feet  can  be  rotated  in  or  out  by 
lengthening  or  shortening  straps 
passing  before  and  behind  the 
body.  Braces  jointed  at  the  knee 
are  sometimes  employed,  but  they 
are,  as  a  rule,  ineffective  except 
in  the  slighter  cases  in  which  the 
deformity  depends  upon  laxity  of 
ligaments  rather  than  distortion 
of  bone. 

DUEATION  OF  TeEATMENT  BY 

Braces.  The  duration  of  the 
brace  treatment  depends,  of  course,  upon  the  degree  of  deformity, 
the  age  of  the  child,  and  upon  the  efficiency  of  the  apparatus. 
From  six  months  to  one  year  of  treatment  by  this  means  is 
usually  required.  The  cure  is  assured  by  the  gradual  adaptation 
of  the  parts  to  the  new  static  conditions.  The  contracted  tissues 
of  the  outer  aspect  of  the  joint  become  lengthened  ;  the  lax  liga- 
ments on  the  inner  side  contract ;  the  internal  structure  of  the 
condyles  and  of  the  adjoining  diaphysis  is  gradually  transformed 
and  at  the  external  contour  of  the  bone  becomes  correspondingly 
straighten  When  the  braces  are  discarded  attention  should  be 
paid  to  the  attitudes,  and  the  exorcises  that  have  been  mentioned 
should  be  continued  in  order  that  relapse  may  be  prevented. 


Long  braces  for  genu  valgum. 
(Bradford  and  Lovett.) 


572  OR THOPEDIC  S  UB GEB  Y. 

The  Plaster  Bandage.  When  the  bones  are  yielding,  as 
in  the  deformity  in  young  children,  it  may  be  corrected  rapidly 
by  the  repeated  applications  of  plaster  bandages,  the  limbs  being 
straightened  as  far  as  possible  without  causing  discomfort  at  each 
sitting,  or  it  may  be  corrected  at  once  under  the  influence  of 
anaesthesia,  which  is  the  better  method. 

Operative  Treatment.  Immediate  correction  of  the  deformity, 
when  it  is  at  all  marked,  is,  as  a  rule,  indicated  after  the  age  of 
four  or  five  years,  and  is  a  satisfactory  treatment  at  any  age 
except  during  the  period  of  active  rhachitis.  It  is  perhaps 
needless  to  remark  that  the  necessity  for  operation  implies 
neglect  of  proper  preventive  treatment  or  the  failure  of  the 
manipulative  and  mechanical  methods,  because  of  their  im- 
proper application.  While  it  is  possible  to  correct  deformity 
of  the  bones  by  mechanical  treatment  in  cases  far  beyond  this 
limit  of  age,  yet  the  time  required  and  the  discomforts  of  the 
treatment  exclude  it  in  all  but  very  exceptional  cases. 

Osteotomy.  At  the  Hospital  for  Ruptured  and  Crippled 
osteotomy  is  usually  performed  in  the  treatment  of  genu  valgum 
by  means  of  the  small  Yance  osteotome,  the  so-called  "  sub- 
cutaneous osteotomy"  (Fig.  316). 

The  limb  having  been  prepared  in  the  usual  manner  is  semi- 
flexed, and  the  inner  surface  of  the  knee  is  placed  on  a  firm  sand- 
bag. With  the  fingers  the  femur  is  firmly  grasped  just  above 
the  condyles,  so  that  its  size  and  position  may  be  accurately 
determined,  and  the  sharp  osteotome  about  the  size  of  a  lead- 
pencil  is  forced  with  its  cutting  edge  parallel  to  the  axis  of  the 
thigh  down  to  the  bone,  at  a  point  about  one  and  a  half  inches 
above  the  external  tuberosity.  While  it  is  held  firmly  in  position 
against  the  bone  it  is  turned  to  the  transverse  direction  and  is 
then  driven  through  the  cortex.  When  it  enters  the  medullary 
canal,  as  is  made  evident  by  the  lessened  resistance,  it  is  partly 
withdrawn  and  moved  slightly  to  one  side  and  the  other,  and 
driven  through  the  cortical  substance  until  by  gentle  force  the 
bone  may  be  fractured.  The  osteotome  is  then  withdrawn  ;  the 
minute  wound  is  covered  with  a  pad  of  dry  gauze,  or,  if  the 
oozing  is  profuse,  it  may  be  closed  with  a  catgut  suture.  The  de- 
formity is  then  overcorrected  sufficiently  to  simulate  well-marked 
genu  varum,  and  a  plaster  spica  bandage  is  applied.  If  the  defor- 
mity is  bilateral  both  limbs  are  operated  upon  at  the  same  sitting. 

The  plaster  bandage  is  continued  for  from  four  to  six  weeks, 
and  it  is  then  usually  supplemented  by  a  brace,  which  may  be 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.      573 

worn  with  advantage  for  several  months,  because  of  the  laxity 
of  the  ligaments  of  the  knee-joint,  which  usually  accompanies 
extreme  deformity  of  rhachitic  origin.  In  less  marked  cases  and 
in  older  subjects  the  support  is  unnecessary.  Massage  and 
exercises  during  the  stage  of  recovery  should  be  employed  if 
possible. 

Incomplete  osteotomy  and  fracture  in  the  manner  described 
has  been  employed  at  the  Hospital  for  Ruptured  and  Crippled  in 
a  very  large  number  of  cases  without  a  single  unfavorable  result. 
The  discomfort  is  insignificant,  and  confinement  to  the  bed  after 
the  third  day  is  unnecessary. 

Cuneiform  Osteotomy.  In  the  more  extreme  cases  of 
general  rhachitic  deformity  of  the  lower  extremity  in  which  the 

Fig.  346. 


The  Grattan  osteoclast. 


tibia  is  implicated,  it  is  sometimes  advisable,  in  addition  to  the 
osteotomy  of  the  femur,  to  remove  a  cuneiform  section  of  bone 
from  the  inner  side  of  the  tibia  just  below  the  epiphysis,  in  order 
to  straighten  the  leg  completely.  In  such  cases  it  is  better  to 
perform  the  second  operation  at  a  later  time,  in  order  that  the 
effect  of  the  femoral  osteotomy  may  be  observed.  In  exceptional 
cases  the  deformity  may  be  practically  confined  to  the  tibia  ;  in 
such  instances  it  should  be  corrected  by  a  primary  cuneiform  or 
linear  osteotomy. 

Osteoclasis.  Osteoclasis,  by  means  of  the  Grattan  osteoclast, 
is  an  effective  operation.  With  this  instrument  the  bone  may  be 
broken  above  the  condyles  at  the  desired  point.  The  lower 
resistant  bar  is  applied  over  the  external   condyle,   the  upper 


574  ORTHOPEDIC  S UE QER  Y. 

about  four  inches  higher.  The  limb  is  then  firmly  fixed  by  the 
hands  of  an  assistant,  and  the  breaking  bar  is  screwed  rapidly 
home,  breaking  or  bending  the  bone  at  the  point  of  election. 
The  deformity  is  then  overcorrected  in  the  manner  described. 
JSTot  infrequently  in  rhachitic  cases  the  principal  or  primary  dis- 
tortion is.  of  the  tibia.  In  such  cases  the  correction  is  made  at 
this  point.  If  it  is  necessary  to  operate  upon  both  the  femur 
and  the  tibia  the  osteoclast,  which  bends  and  breaks,  is  to  be 
preferred  to  osteotomy. 

The  adolescent  type  of  genu  valgum  is  not  often  extreme. 
As  a  rule,  the  deformity  of  the  bone  is  of  comparatively  short 
duration,  and  it  is  accompanied  by  considerable  laxity  of  liga- 
ments. In  the  more  chronic  cases  the  osteotomy  above  the 
condyles  may  be  performed  in  the  manner  described,  but  in 
Berlin  and  Vienna,  where  the  deformity  is  more  common  than 
in  New  York,  other  procedures  are  often  employed. 

Wolff's  Treatment.  One  method  is  that  of  Wolff,  who  by 
means  of  the  "  Etappen  Verband  "  gradually  corrects  the  deformity. 

The  patient  is  anaesthetized,  and  the  limb,  having  been  care- 
fully protected  with  cotton,  particularly  so  about  the  malleoli, 
the  patella,  and  the  inner  condyle,  is  enveloped  in  a  firm  plaster 
bandage  reaching  from  the  malleoli  to  the  pubes.  When  the 
plaster  begins  to  harden  one  assistant  steadies  tbe  pelvis,  another 
holds  the  inner  condyle,  while  the  operator  draws  the  leg 
inward  with  moderate  but  persistent  force  against  the  fulcrum 
formed  by  the  hand  of  the  second  assistant,  and  holds  it  firmly 
in  the  partly  corrected  position  until  the  bandage  is  firm.  About 
three  days  later  a  wedge-shaped  section  of  the  bandage  about  one 
inch  in  width  is  removed  from  the  part  that  covers  the  inner 
half  of  the  knee,  the  outer  half  of  the  bandage  being  simply 
divided.  The  leg  is  then  forced  inward  until  the  two  sections 
are  again  brought  into  contact.  The  position  is  retained  by  an 
additional  plaster  bandage  about  the  weakened  part.  This  pro- 
cedure is  repeated  at  intervals  until  the  leg  is  completely 
straightened — a  result  that  is  often  accomplished  in  two  weeks. 
No  anaesthetic  is  required  for  the  secondary  corrections.  When 
the  deformity  has  been  corrected  the  patient  is  allowed  to  walk 
about,  and  for  convenience  the  plaster  bandage  is  divided  into  a 
thigh  and  leg  part,  which  are  attached  by  lateral  joints  incor- 
porated in  its  substance  so  that  motion  is  allowed.  This 
apparatus  must  be  worn  for  several  months,  and  is,  of  course,  to 
be  supplemented  by  massage  and  exercises. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     575 

LoEENz's  Operation.  Another  means  of  correction  of  de- 
formity without  open  operation  is  that  employed  by  liorenz, 
what  he  calls  ''  Intra-articulare  modelirerende  redressement." 
In  this  operation  the  deformity  is  reduced  under  anaesthesia 
at  one  sitting  by  the  gradual  application  of  force  by  means  of 
the  Lorenz  osteoclast.  The  reduction  depends  partly  upon  the 
stretching  of  the  external  ligaments  and  partly  upon  the  actual 
bending  of  the  diaphysis  of  the  bone,  as  in  the  Wolff  method, 
and  sometimes  upon  actual  separation  of  the  epiphysis. 

When  the  limb  has  been  straightened,  or  somewhat  overcor- 
rected  even,  a  long  plaster  bandage  is  applied  which  is  worn  for 
six  weeks  and  is  then  replaced  by  a  jointed  walking  brace  to 
be  worn  for  about  a  year.  The  operation  is  not  attended  by 
severe  pain,  and  the  patient  is  usually  allowed  to  walk  about  in 
a  few  days. 

Genu  Varum. 

Synonym.      Bow-leg. 

The  term  bow-legs  includes,  in  its  popular  sense,  all  the  dis- 
tortions that  cause  a  separation  of  the  knees  when  the  ankles  are 
in  contact  with  one  another.  But,  strictly  speaking,  genu  varum 
is  the  reverse  of  genu  valgum — that  is,  the  principal  distortion  is 
at  or  near  the  knee-joint — while  bow-leg,  as  the  name  implies, 
is  a  simple  bowing  of  the  tibia  and  fibula,  as  a  rule  near  the 
ankle-joint  (Fig.  347).  In  true  genu  varum  a  line  dropped 
from  the  head  of  the  femur  falls  inside  the  knee  (Fig.  333)  ;  the 
inner  condyle  of  the  femur  and  the  inner  tuberosity  of  the  tibia 
bear  the  greater  part  of  the  weight ;  the  outer  condyle  is  on  the 
same  level  or  somewhat  lower  than  the  internal,  and  the  outer 
tuberosity  of  the  tibia  may  be  somewhat  higher  than  the  internal. 
The  femur  is  abducted  and  rotated  outward ;  the  tibia  is  rotated 
inward.  These  changes,  it  will  be  noted,  are  the  reverse  of  those 
found  in  genu  valgum.  As  has  been  stated,  the  deformity  of 
genu  valgum  disappears  when  the  legs  are  flexed,  and  in  genu 
varum,  if  the  legs  are  flexed  and  the  knees  are  placed  in  contact 
with  one  another,  the  malleoli  may  be  actually  separated,  simu- 
lating the  deformity  of  knock-knee  (Fig.  348).  This  is  explained 
by  the  inward  rotation  of  the  femora,  necessitated  by  placing  the 
knees  in  contact  with  one  another. 

In  genu  varum  the  distortion  of  the  bones  is  not  as  strictly 
confined  to  the  neighborhood  of  the  knee-joint  as  in  genu  valgum, 
and  in  sim])lo  bow-leg  there  is  almost  always  a  certain  amount  of 


576 


ORTHOPEDIC  SURGERY. 


distortion  at  the  knee,  dependent,  in  part,  upon  laxity  of  the 
ligaments.  It  is  proper,  therefore,  to  use  the  two  terms 
synonymously,  although  one  must  recognize  a  decided  difference 
between  the  genu  varum  type,  in  which  the  deformity  is  greatest 
at  the  knee,  and  which  is  accompanied,  as  a  rule,  by  marked 


Fig.  347. 


Fig.  348. 


The  genu  varum  type  of  bow-legs,  showing 
the  outward  rotation  of  the  femora. 


The  same  patient,  showing  the  separa- 
tion of  the  malleoli  when  the  knees  are  in 
contact. 


laxity  of  the  ligaments  (Fig.  333),  and  the  bow-leg  type,  in  which 
the  deformity  may  be  strictly  confined  to  the  lower  third  of  the 
leg  (Fig.  353). 

Symptoms.      As  was   said  of  genu  valgum,  the  deformity  is 
the  principal  symptom.     The  gait  is  somewhat  rolling,  because 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     577 

each  foot  must  describe  a  part  of  the  arc  of  a  circle  before  reach- 
ing the  ground  ;  and  because  of  the  inward  rotation  of  the  tibiae, 
or  because  of  the  inward  spiral  twist  of  the  bone  that  is  some- 
times present,  patients  often  toe-in  in  walking. 

Except  in  extreme  cases  the  weakness  and  awkwardness  char- 
acteristic of  genu  valgum  are  absent.  This  may  be  explained  by 
the  fact  that  the  relation  of  the  bones  is  such  that  the  general 
attitude  is  one  of  activity,  the  weight  falling  on  the  outer  side  of 
the  feet ;  thus  flat-foot  is  uncommon  as  an  accompaniment  of  bow- 
leg, except  in  the  early  or  rhachitic  type. 


Fig.  349. 


Genu  varum  of  rhachitic  origin  iu  an  adult. 

Measurements.  The  full  effect  of  the  deformity  appears  only 
when  the  weight  of  the  body  is  borne,  but  for  practical  purposes 
the  tracing  of  the  extended  legs  is  the  l)est  method  of  recording  the 
fixed  deformity.  In  true  genu  varum  the  deformity  is  greatest 
at  the  knee,  and  in  the  distortion  the  apposed  surfaces  of  the 
femur  and  of  the  tibia  ])artici[)ate. 

In  simple  bow-leg  the  deformity  may  be  confined  to  the  tibia, 

37 


578 


OB  THOPEDIC  &  UB  GEB  Y. 


Fig.  350. 


which,  in  addition  to  the  outward  bowing,  may  be  twisted  inward 
somewhat  upon  its  long  axis. 

Genu  varum  may  be  unilateral  or  it  may  be  combined  with 
genu  valgum  of  its  fellow  (Fig.  341),  and  occasionally   slight 
knock-knee  and  slight  bow-leg  may  be  present  in  the  same  limb. 
Treatment.     Expectant  Treatment.     The  slighter  cases  of  bow- 
leg in  early  childhood  may  be  treated  by  manipulation.      The 

leg,  grasped  firmly  at  the  ankle  and 
at  the  knee,  is  straightened  with  a 
certain  amount  of  force  over  and 
over  again.  Gradual  correction  by 
this  means  may  be  hastened  by  mak- 
ing the  sole  of  the  shoe  slightly 
thicker  on  the  outer  border.  This 
aids  also  in  correcting  the  secondary 
pigeon-toe,  but  if  the  foot  is  weak, 
as  it  usually  is  in  rhachitic  cases, 
this  method  should  not  be  employed, 
as  it  miffht  induce  flat-foot. 

Treatment  by  Braces.  If  the  de- 
formity is  more  extreme,  or  if  im- 
provement does  not  follow  expectant 
treatment,  apparatus  should  be  em- 
ployed. If  the  distortion  is  confined 
to  the  lower  third  of  the  tibia,  a 
Knight  brace  may  be  used.  It  con- 
sists of  two  uprights  attached  to  a 
foot  plate  ;  the  inner  bar  is  provided 
with  a  pad  at  its  upper  end  for 
pressure  on  the  internal  condyle  of 
the  femur.  The  outer  bar  reaches  to  the  head  of  the  fibula, 
and  the  two  are  joined  by  a  calf  band.  When  applied  the  leg  is 
drawn  toward  the  inner  upright  by  means  of  a  lacing,  which 
passes  about  it  within  the  outer  bar.  When  the  lacing  is  made 
fast,  the  outer  bar  is  bent  toward  the  leg,  and  thus  it  aids  some- 
what in  supporting  it  in  an  improved  position.  The  foot  plate 
may  be  dispensed  with,  and  the  brace  may  be  attached  to  the 
shoe,  and  even  the  outer  bar  may  be  removed,  leaving  only  the 
upright,  which  is  held  in  position  by  the  lacing.  The  apparatus, 
then,  has  the  appearance  of  a  gaiter,  and  has  the  advantage 
of  being  inconspicuous,  although  somewhat  less  effective  than 
the  Knight  brace.     By  this  apparatus,  combined  with  vigorous 


Long  braces  for  genu  varum. 
(Bradford  and  Lovett.) 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY.     579 

manipulation,  the  deformity  may  be  corrected,  in  young  children, 
in  about  six  months. 

If  the  outward  bowing  of  the  knee  is  marked,  another  form  of 
apparatus  will  be  necessary,  and  its  effectiveness  will  be  much 
increased  if  there  is  no  joint  at  the  knee.  The  outer  bar,  shaped 
to  the  contour  of  the  leg,  is  attached  above  to  a  pelvic  band  and 
below  to  a  foot  plate,  as  is  the  short  brace.  An  inner  straight 
bar  extends  to  the  upper  third  of  the  thigh,  and  is  attached  to 
the  outer  bar  by  a  thigh  band.  This  inner  upright  is  provided 
with  a  lacing  of  leather  or  canvas,  similar  to  that  of  the  short 
brace,  which  surrounds  the  knee  and  upper  part  of  the  leg,  and 
thus  draws  it  toward  an  improved  position.  The  outer  bar  is 
then  bent  slightly  inward  and  serves  as  an  additional  support. 
Another  form  of  apparatus  consists  of  a  single  upright,  attached 
to  the  shoe  and  extending  upward  as  high  as  possible  on  the 
inner  aspect  of  the  thigh.  At  its  upper  extremity  a  pressure  pad 
is  placed  and  the  knee  is  drawn  toward  it  by  means  of  straps 
or  bandages. 

An  improved  brace  of  this  kind  is  that  in  use  at  the  Boston 
Children's  Hospital,  in  which  the  upper  part  of  the  upright  is 
curved  upward  and  outward  just  below  the  groin,  to  a  point  on 
a  level  with  and  behind  the  trochanter,  and  is  attached  to  its 
fellow  by  means  of  a  strap  passing  across  the  buttocks  so  that 
the  feet  may  be  somewhat  rotated  outward  if  necessary  (Fig. 
350). 

Operative  Treatment.  In  children  more  than  five  years  of 
age,  and  in  cases  of  the  more  extreme  type  at  an  earlier  age,  or 
when  the  opportunity  for  mechanical  treatment  is  lacking,  imme- 
diate correction  of  the  deformity  is  indicated.  Either  osteoclasis 
or  osteotomy  may  be  employed,  and  in  some  instances  manual 
force  is  sufficient  for  the  correction  of  the  deformity.  There  is 
but  little  choice  between  the  methods.  Osteoclasis  is  somewhat 
safer  possibly,  and  is  to  be  preferred  for  the  younger  patients. 

At  the  Hospital  for  Ruptured  and  Crippled,  osteotomy  is 
almost  always  performed.  The  small  osteotome  is  inserted  on 
the  inner  aspect  of  the  tibia  at  the  point  of  greatest  deformity, 
and  when  the  bone  has  been  sufficiently  weakened  the  fracture  is 
completed  by  manual  force.  The  fibula  may  be  broken  at  the 
same  time,  or,  as  is  usually  the  case,  it  may  be  simply  bent  out- 
ward. The  deformity  is  overcorrected,  and  a  well-fitting  plaster 
bandage,  including  the  foot  and  extending  to  the  trochanter,  is 
applied. 


580 


ORTHOPEDIC  SURGERY. 


The  patient  usually  remains  in  bed  for  a  few  days  ;  he  is  then 
dressed,  and  if  he  so  desires  is  allowed  to  stand.  Almost  no  pain 
or  discomfort  follows  the  operation,  and,  in  fact,  in  properly 
selected  cases,  it  is  not  only  free  from  danger,  but  it  has  a  very 
decided  advantage  over  the  simple  mechanical  treatment.  If  the 
child  is  in  good  condition,  and  if  the  deformity  is  overcorrected 
at  the  time  of  operation,  apparatus  will  not  be  required  in  the 
after-treatment ;  but  in  many  instances  some  form  of  support  is 
indicated,  usually  because  slight  deformity,  due  to  laxity  of  liga- 
ments or  to  deformity  of  the  femur,  appears  when  the  weight  of 
the  body  falls  upon  the  legs. 

It  has  been  stated  that  the  deformity  of  bow-leg  depends  in 
part  upon  a  distortion  of  the  femur  as  well  as  of  the  tibia.  As 
a  rule,  the  correction  of  the  greater  deformity  of  the  tibia  will 

be  sufficient,  but    in    more 
^^°-  ^^^-  extreme  cases   a   secondary 

osteotomy  above  the  con- 
dyles will  be  necessary. 
This  may  be  performed 
simultaneously  with  that  on 
the  tibia,  but  it  is  better  to 
defer  it  until  the  effect  of  the 
primary  operation  has  been 
observed. 

Anterior  Bow-leg. 

Synonym.    Anterior  cur- 
vature of  the  tibia. 

Both  bow-legs  and  knock- 
Anterior  bow-legs.  knees  are  often  seen  in  chil- 
dren who  present  no  signs 
of  general  rhachitis,  but  anterior  bowing  of  the  legs  is  almost 
always  combined  with  general  rhachitic  distortions  of  the  lower 
extremity,  most  often  with  knock-knees  ;  these  in  turn  are 
caused  by  marked  distortion  of  the  femora,  which  may  be  bent 
forward  and  outward  above,  and  inward  at  their  lower  extremi- 
ties, "  corkscrew  deformity."  In  anterior  bow-legs  the  tibia?  are 
usually  flattened  from  side  to  side,  curved  inward  or  outward 
and  bent  forward,  the  projecting  crests  presenting  sharply  beneath 
the  skin. 

Symptoms.  The  effect  of  the  anterior  bowing  is  to  throw  the 
weight  forward  upon  the  foot ;  thus  the  heels  appear  abnormally 


Fig.  352. 


Long  anterior  curvature  of  the  tibia  and  flat-foot. 
Fig.  353. 


iitiachilic  anterior  bow-legs. 


582  ORTHOPEDIC  SURGERY. 

long  and  prominent,  and  the  patient  seems  to  sink  forward  at 
each  step  (Fig.  353).  The  knees  are  usually  somewhat  flexed, 
partly  as  the  effect  of  knock-knee,  with  which  the  deformity  is 
usually  combined,  and  the  feet  are,  as  a  rule,  flat.  As  has  been 
stated,  anterior  bowing  is  almost  never  seen  as  an  independent 
deformity  unless  it  is  a  relic  of  the  more  general  distortion  which 
has  been  "  outgrown." 

Treatment.  Anterior  curvature  of  the  tibia  must,  as  a  rule, 
be  treated  by  operation.  After  complete  fracture  of  the  tibia 
and  fibula,  the  deformity  may  be  overcome  by  forcing  the  bones 
directly  backward.  In  many  instances  tenotomy  of  the  tendo 
Achillis  may  be  required.  Cuneiform  osteotomy  of  the  tibia 
permits  more  perfect  correction,  but  the  final  result  is  equally 
good  after  simple  osteotomy  or  osteoclasis,  and  if  one  succeeds  in 
separating  the  posterior  part  of  the  tibia  so  that  it  may  conform 
to  the  straightened  anterior  border  an  actual  elongation  may  be 
obtained. 

General  Rhachitic  Distortions, 

General  rhachitic  distortions  of  the  lower  limbs  have  been 
mentioned  in  connection  with  knock-knee  and  with  anterior 
bow-leg.  A  more  extended  description  is  hardly  necessary. 
The  deformities  are  usually  of  the  knock-knee  type,  and  they 
may  be  treated  on  the  same  general  plan  that  has  been  outlined 
in  the  description  of  the  less  extreme  distortions. 


CHAPTER  XYII. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

From  the  orthopedic  standpoint  only  those  diseases  that 
directly  interfere  with  the  function  of  locomotion  or  that  cause 
deformity  and  for  which  local  treatment  is  of  benefit  are  of 
special  interest.  Even  this  limited  class  is  not  often  seen  in 
the  early  or  progressive  stage,  and  it  is  rather  with  the  effects  of 
a  disease  that  is  no  longer  present  than  with  the  disease  itself 
that  the  orthopedic  surgeon  is  especially  concerned. 

The  relative  importance  of  this  branch  of  orthopedic  work  may 
be  illustrated  by  the  statistics  of  the  Hospital  for  Ruptured  and 
Crippled.  In  a  period  of  ten  years — 1890-1899 — 42,124  new 
patients  were  examined  in  the  out-patient  department.  Exclud- 
ing cases  that  cannot  properly  be  classed  as  orthopedic,  38,419 
remain.  In  2441  of  these  the  nervous  system  was  involved  (6.3 
per  cent.)  ;  2028  of  the  cases  were  in  young  children  ;  413  of 
the  patients  were  more  than  fourteen  years  of  age,  and  of  this 
number  266  were  adults. 

Anterior  poliomyelitis  furnished  about  75  per  cent,  of  the 
total  number.  In  20  per  cent,  the  cerebrum  was  involved,  and 
5  per  cent,  were  miscellaneous  cases.  In  611  cases  treated  in  a 
period  of  about  two  years  there  were  463  cases  of  poliomyelitis, 
121  cases  of  paralysis  of  cerebral  origin,  16  cases  of  obstetrical 
paralysis,  4  cases  of  pseudohypertrophic  muscular  paralysis,  and 
7  miscellaneous  cases.  These  statistics  will  explain  the  selection 
of  diseases  of  the  nervous  system  for  consideration  and  the  order 
in  which  they  are  described. 

Acute  Anterior  Poliomyelitis. 

Synonym.     Infantile  paralysis. 

Pathology.  Anterior  poliomyelitis  is  an  acute  inflammatory 
process  of  the  area  of  the  gray  matter  of  the  anterior  cornua  sup- 
plied by  the  anterior  spinal  arteries.  It  involves  both  the  neu- 
roglia and  the  cells,  and  it  results  in  degeneration  and  atrophy 
of  the  interstitial  tissue  and  of  the  ganglion  cells.^ 

'  Starr,  Loomis-Thompson.    System  of  Practical  Merliciiie. 


584 


ORTHOPEDIC  SUEGEBY. 


In  the  acute  febrile  form,  comprising  about  three-fourths  of 
the  cases,  there  is  an  actual  inflammation  ;  in  the  other  type  in 
which  the  paralysis  is  of  sudden  onset  unaccompanied  by  consti- 
tutional evidences  of  disease,  the  symptoms  may  be  caused  by 
hemorrhage  or  by  thrombosis. 

The  minute  changes  in  the  cord  are  characteristic  of  inflanima- 
tion,  distended  bloodvessels,  minute  hemorrhages,  infiltrating 
leucocytes,  and  serum.  In  the  early  stage  the  motor  cells  become 
cloudy  in  appearance,  later  they  are  swollen  and  lose  their  distinct 
outlines.  The  degenerative  changes  affect  both  the  cells  and 
neuroglia  ;  the  affected  gray  matter  shrinks  and  the  nerve  fibres 
atrophy,  and  the  cord  becomes  distinctly  smaller  at  the  seat  of 
the  disease.  When  the  motor  conductivity  of  the  cells  is  cut  off, 
the  muscles  which  are  supplied  by  them  are  paralyzed  and  waste 
away.  The  circulation  in  the  affected  parts  is  impaired,  con- 
tractions and  distortions  appear,  and  growth  is  retarded. 

Etiology.  The  etiology  of  the  disease  is  obscure.  Exposure  to 
heat,  sudden  chilling  of  the  body,  overfatigue,  injury  and  the  like 
are  thought  to  be  predisposing  causes.  The  direct  cause  of  inflam- 
matory disease  of  the  cord  is  supposed  to  be  some  form  of  infection. 

The  disease  affects  the  sexes  in  nearly  equal  numbers,  and 
those  in  perfect  health  as  often  as  those  whose  resistance  is 
enfeebled.  It  sometimes  occurs  in  epidemics,  and  there  are 
instances  in  which  several  members  of  the  same  family  have  been 
affected,  but  usually  the  cases  are  isolated  and  no  adequate  cause 
for  the  disease  can  be  assigned. 

Age.  Acute  anterior  poliomyelitis  is  essentially  a  disease  of 
infancy.  This  is  illustrated  by  the  combined  statistics  of  several 
observers  tabulated  by  Starr.^ 


^ 

^■ 

^ 

t^ 

tj 

a 

d 

s 

03 

oj 

S3 

IS 

cS 

S3 

<u 

v 

<u 

OJ 

k. 

P»> 

p-l 

>, 

>> 

P>. 

>• 

>, 

>> 

_^ 

Xi 

.C 

fl 

X3 

.a 

^ 

A 

C4 

CO 

1 

iO 

CO 

"^ 

0 

Seeligmnller   .       .       .    ■ 

20 

25 

18 

1 

2 

0 

0 

0 

Galbraith 

17 

38 

15 

4 

1 

0 

0 

0 

0 

0 

Sinkler    .... 

44 

92 

55 

29 

9 

2 

3 

6 

0 

3 

Gowers     .... 

21 

21 

25 

9 

17 

4 

2 

6 

4 

0 

Starr         .... 

16 

38 

27 

9 

10 

4 

2 

2 

4 

3 

118 

214 

140 

52 
cent., 

38 
before 

12 

7 

14 

8 

6 

172,  or 

77  per 

Ihefo 

urth  y 

Jar. 

It  is  far  more  common  during  the  warm  months  than  at  other 
seasons,  as  is  illustrated  in  452  cases  tabulated  by  Starr.^ 


'  Loomis-Tbomison.    System  of  Practical  Medicine. 


2  Loc.cit. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


585 


327,  or  72  per  cent., 
during  the  four 
months,  June  to 
September. 


January   8 

February 5 

March 20 

April 9 

May 18 

June 49  1 

July .....  97    [ 

August 116    I 

September 65  J 

October 42 

November 11 

December 12 

452 

Distribution  of  the  Paralysis.  The  lower  extremities  are  far 
more  often  paralyzed  than  the  upper.  In  416  of  595  cases, 
tabulated  by  Starr,  the  paralysis  was  limited  to  the  lower  extrem- 
ities, as  contrasted  with  53  cases  in  which  the  upper  extremities 
were  alone  involved. 

Duchenne,    Seeligmuller.    Sinkler.       Starr.        Total. 


Both  legs 

9 

14 

107 

40 

170 

Right  leg 

25 

15 

63 

20 

123 

Left  leg     . 

7 

27 

62 

27 

123 

Right  arm 

5 

9 

5 

7 

26 

Left  arm  . 

5 

4 

8 

4 

21 

Both  arms 

2 

1 

1 

2 

6 

All  extremities 

5 

2 

35 

5 

47 

Arm  and  leg  same 

side 

1 

2 

26 

4 

33 

Arm  and  leg  opposite  sides 

2 

1 

1 

4 

8 

Trunk 

1 

0 

22 

3 

26 

Three  extremities 

0 

0 

10 

2 

12 

75 


Symptoms.     The  disease  is  usually  divided  into  several  stages  : 

1.  The  stage  of  onset.  This  is  usually  attended  by  constitu- 
tional symptoms,  by  fever  and  headache,  even  by  convulsions 
and  delirium  ;  by  vomiting  and  intestinal  disturbance,  or  occa- 
sionally by  severe  pain.  In  most  instances  the  elevation  of  the 
temperature  is  not  extreme,  nor  is  the  constitutional  disturbance 
severe,  and  but  for  the  paralysis  the  attack  would  be  considered 
as  one  of  the  ordinary  illnesses  so  common  in  childhood.  In 
some  cases,  however,  the  fever  is  high,  and  there  may  be  con- 
vulsions and  prolonged  unconsciousness,  while  in  others  there 
may  be  no  premonitory  symptoms  whatever ;  the  child  is  appar- 
ently well  at  night,  but  wakens  in  the  morning  paralyzed. 

In  many  instances  the  weakness  or  paralysis  caused  by  anterior 
poliomyelitis  of  a  mild  type  is  not  discovered  until  the  child 
begins  to  walk,  when  the  awkward  gait,  or  limp,  or  the  distortion 
of  a  foot,  may  make  it  evident. 

In  a  few  hours  or  a  few  days  after  the  first  symptoms  of  the 
disease  the  paralysis  appears  ;  its  area  may  extend  slowly  after 


586  OB THOPEDIC  S UB GEB  Y. 

it  is  recognized,  or  its  extreme  limit  may  be  reached  at  once. 
This  original  paralysis  is  always  greater  than  that  which  finally 
persists.  The  duration  of  the  first  stage  may  be  from  a  few 
hours  to  a  week. 

2.  Then  follows  a  stationary  period,  lasting  from  a  week  to  a 
month  ;  the  constitutional  symptoms  cease,  but  the  paralysis 
remains. 

3.  This  is  succeeded  by  the  stage  of  partial  recovery,  lasting 
from  one  to  six  months  or  longer.  The  muscles  which  were 
paralyzed  because  of  the  secondary  congestion  and  exudation 
about  the  local  myelitis,  recover  their  power  in  whole  or  in  part, 
while  those  muscles  supplied  from  the  area  in  the  cord  in  which 
the  nerve  cells  have  been  destroyed,  Avaste  away.  At  this  time 
the  contractions  and  distortions  in  the  paralyzed  limbs  appear. 

4.  The  chronic  stage.  This  may  be  considered  to  last  until 
adult  age  or  until  the  ultimate  damage  to  the  individual,  due  to 
the  retardation  of  the  growth  and  unbalancing  of  the  mechanical 
equilibrium  of  the  body  may  be  summed  up. 

The  sensation  of  the  paralyzed  part  is  not  affected  except  in 
the  extreme  cases.  The  temperature  is  lower  from  the  first.  In 
many  instances  the  limb  is  not  only  cold,  but  it  is  congested  and 
blue.  These  circulatory  disturbances  are  caused  primarily  by 
the  interference  with  the  vasomotor  system,  but  they  are  con- 
firmed later  by  the  atrophy  of  the  muscles  and  by  the  permanent 
contraction  of  the  bloodvessels.  Thus,  in  general,  the  impair- 
ment of  the  circulation  corresponds  to  the  degree  of  the  paralysis, 
but  not  absolutely  so.  In  certain  cases  the  paralysis  may  be 
limited  in  extent,  and  yet  the  limb  may  be  cold  and  congested, 
while  in  others  in  which  the  loss  of  power  is  much  greater  the 
temperature  is  but  slightly  lowered  and  the  color  remains 
normal.  The  same  is  true  of  retardation  of  growth.  In  most 
instances  the  ultimate  shortening  of  the  limb  corresponds  to  the 
degree  of  the  paralysis  and  consequent  loss  of  function  ;  but 
occasionally  cases  are  seen  in  which  the  growth  is  markedly 
retarded,  although  but  few  of  the  muscles  are  paralyzed. 

Diagnosis.  It  is  doubtful  if  the  diagnosis  of  acute  anterior 
poliomyelitis  could  be  made  before  the  stage  of  paralysis.  But 
after  the  paralysis  has  appeared  there  should  be  little  difficulty 
in  interpreting  the  symptoms.  It  is  a  disease  usually  of  acute 
onset,  followed  by  paralysis  of  certain  muscular  groups  or  of 
entire  members.  It  is  a  flaccid  paralysis,  the  reflexes  are  lost, 
the  muscles  no  longer  contract  under  faradism,  and  the  reaction 


DISEASES  OF  THE  NERVOUS  SYSTEM.  587 

of  degeneration  soon  appears  ;  the  tissues  waste,  and  the  circula- 
tion is  impaired  in  the  affected  parts. 

It  is  usual  to  consider,  first,  in  differential  diagnosis  the  paralyses 
of  cerebral  origin,  but  this  is  more  for  the  purpose  of  calling 
attention  to  the  essential  differences  between  the  two  than  because 
they  are  likely  to  be  confounded  by  one  acquainted  with  the 
ordinary  characteristics  of  cerebral  and  spinal  disease. 

Paralysis  of  Cerebral  Origin  in  Childhood.  In  paralysis  of  cere- 
bral origin  the  common  form  is  hemiplegia.  It  usually  follows 
convulsions,  and  the  intelligence  may  l)e  impaired.  The  paralysis 
is  not  complete,  nor  is  it  limited  to  groups  of  muscles  ;  it  is 
rather  powerlessness  or  impairment  of  function,  due  to  loss  of 
cerebral  control.  The  reflexes  are  increased  and  limbs  are 
stiffened,  not  flaccid.  The  electrical  reactions  are  not  lost  or 
changed  in  quality.  Paralysis  of  cerebral  origin  may  be  also 
paraplegic  or  diplegic  in  its  distribution,  but  in  these  cases  the 
general  characteristics  are  the  same  as  in  the  hemiplegic  form, 
except  that  the  intelligence  is  more  markedly  affected. 

Other  Forms  of  Spinal  Paralysis.  Transverse  myelitis  is  very 
uncommon  in  childhood.  In  this  disease  the  distribution  is 
equal,  the  reflexes  are  at  first  increased,  and  sensation  as  well  as 
motion  is  lost. 

Pott's  Paraplegia.  In  this  form  of  paralysis,  also,  the  distribu- 
tion is  equal,  the  reflexes  are  increased,  and  the  signs  of  the 
disease  of  the  spine  are  always  present. 

Spastic  Spinal  Paraplegia.  In  this  as  in  the  preceding  form 
the  distribution  is  equal,  and  the  reflexes  are  exaggerated. 

Rheumatism  and  Joint  Disease.  In  orthopedic  practice  anterior 
poliomyelitis  is  not  often  seen  in  the  stage  of  onset  unless  pain 
is  a  prominent  symptom,  when  the  disease  may  be  mistaken  for 
rheumatism  or  for  some  form  of  joint  disease.  Cases  of  this 
type  are  not  uncommon.  The  muscles  are  sensitive  to  pressure 
and  the  movements  of  the  joints  cause  discomfort.  In  certain 
instances  the  paralysis  may  not  be  apparent  on  the  first  examina- 
tion ;  when  it  does  appear  the  diagnosis  is,  of  course,  established  ; 
therefore,  the  characteristics  of  diseases  of  the  joints  need  not  be 
detailed. 

Multiple  Neuritis.  Multiple  neuritis  is  usually  a  sequel  of 
infectious  diseases,  or  of  metallic  poisoning.  In  the  cases  due  to 
metallic  poisoning  with  lead  or  arsenic  the  paralysis  usually  begins 
in  the  extensors  of  the  hands  and  feet,  and  is  symmetrical  in  its 
distribution.     This  is  true,  also,  of  the  localized  forms  of  paralysis 


588  ORTHOPEDIC  SURGERY. 

following  contagious  diseases  in  which  the  dorsal  flexors  of  the 
feet  are  most  often  involved.  In  multiple  neuritis  there  is 
usually  local  sensitiveness  lasting  a  longer  time  than  in  poliomye- 
litis ;  the  paralysis  is  gradual  in  its  onset,  and  sensation  as  well 
as  motion  is  affected. 

Diphtheritic  Paralysis.  Diphtheria  is  the  most  common  cause 
of  general  weakness  terminating  in  paralysis,  but  in  these  cases 
there  is  usually  a  history  of  the  preceding  disease.  The  paralysis 
appears  first  in  the  muscles  of  the  throat  and  neck,  and  a  general 
and  increasing  weakness  precedes  for  a  considerable  interval  the 
complete  loss  of  power. 

Weakness.  Pseudoparalysis.  Weakness  caused  by  rhachitis  or 
so-called  pseudoparalysis,  due  to  this  or  to  other  affections,  is 
readily  distinguished  from  actual  paralysis  by  pricking  the  part 
with  a  pin,  when  muscular  contraction  and  movement  of  the  limb 
will  be  evident.  This  test  of  function  is  of  value  in  showing 
the  distribution  of  the  paralysis.  Loss  of  power  in  the  tibialis 
anticus  muscle,  for  example,  causes  valgus  resembling  closely  the 
ordinary  valgus  due  to  simple  weakness.  In  simple  weakness 
the  child  withdraws  the  foot  from  the  point  of  the  pin,  and  the 
ability  to  move  it  in  all  directions  is  very  evident ;  but  if  the 
tibialis  anticus  muscle  is  paralyzed  the  foot  is  always  flexed  in 
the  abducted  attitude.  The  same  test  may  be  made  for  paralysis 
of  other  muscles  or  muscular  groups.  It  is  a  test  that  is  easily 
applied  and  that  is  especially  useful  in  the  examination  of  young 
children. 

Obstetrical  Paralysis.  Paralysis  of  the  arm  due  to  anterior 
poliomyelitis  is  infrequent  as  compared  with  that  of  the  lower 
extremity.  This  form  might  be  mistaken  for  obstetrical  par- 
alysis, but  the  history  of  the  disability  and  its  distribution 
should  make  the  diagnosis  clear. 

Prognosis.  Only  in  very  rare  instances  does  the  disease  of 
itself  cause  death.  The  prognosis  as  to  function  depends  pri- 
marily upon  the  area  of  the  destructive  disease  of  the  cord, 
secondarily  upon  the  treatment  of  the  weakened  or  disabled  part. 

As  has  been  stated,  the  extent  of  the  primary  paralysis  is 
very  much  greater  than  that  which  ultimately  remains  when  the 
inflammatory  changes  about  the  diseased  area  in  the  cord  have 
subsided. 

The  Electrical  Test.  During  the  early  stages  of  the  disease  the 
degree  of  final  paralysis  may  be  fairly  estimated  by  the  electrical 
reaction.     Within  a  week  after  the  initial  paralysis  the  reaction 


DISEASES  OF  THE  NERVOUS  SYSTEM.  589 

to  the  faradic  current  in  the  muscles  and  nerves  in  direct  con- 
nection with  the  diseased  area  is  lessened  and  is  soon  lost.  If 
the  faradic  irritability  is  retained  in  the  paralyzed  muscles,  or  if 
it  is  merely  diminished,  recovery  may  be  predicted.  The  muscles 
which  no  longer  react  to  the  faradic  irritation  may  still  be  made 
to  contract  by  the  galvanic  current.  In  normal  muscles  the 
reaction  is  greatest  at  the  closing  of  the  negative  pole.  In  the 
paralyzed  muscles  the  reaction  is  slower,  it  requires  greater  stimu- 
lation, and  the  contraction  is  greater  at  the  closing  of  the  positive 
pole.     This  is  known  as  the  reaction  of  degeneration.     The  loss 

Fig.  354. 


Anterior  poliomyelitis.    Extreme  flexion  deformity  at  the  hips,  inducing  the 
quadrupedal  attitude.    (Gibney.) 


of  faradic  reaction  and  the  change  in  the  galvanic  reaction  indi- 
cate that  the  function  of  the  afPected  muscle  is  lost,  although  cer- 
tain of  its  fibres  may  in  time  regain  their  power. 

The  Effects  of  Paralysis  of  Different  Muscles  and  Groups  of 
Muscles  upon  Function.  Tlie  interest  in  anterior  poliomyelitis 
lies  in  its  immediate  and  ultimate  effect  upon  the  functional 
ability  of  the  individual.  These  effects  may  be  classified  as 
dcforridiy  of  the  part  direcjii/  hwolved.  'The  general  eff'eds  of 
v)eakneHH,  deformity,  and,  (o.s.s  <f  (/roiutJt  upon  the  body  as  a  lohole. 


590  ORTHOPEDIC  SURGERY. 

Causes  of  Deformity.  The  deformities  of  anterior  poliomyelitis 
are  caused  : 

1.  By  the  force  of  gravity. 

2.  By  the  unopposed  action  of  the  muscles  whose  power 
remains. 

3.  By  functional  use. 

All  these  and  other  less  important  causes  of  deformity  are,  of 
course,  combined  in  most  instances.  The  relative  importance  of 
each  factor  varies,  according  to  the  muscular  group  that  is  in- 
volved, with  the  age  of  the  patient,  and  with  the  strain  to  which 
the  part  is  subjected.  The  influence  of  the  different  factors  can 
be  studied  best  in  the  foot. 

Muscular  Action  and  Gravity.  In  by  far  the  larger  number  of 
cases,  one  or  more  of  the  anterior  muscles  of  the  leg,  the  dorsal 
flexors  of  the  foot  are  involved.  This  is  illustrated  by  the 
statistics  of  acquired  talipes,  tabulated  elsewhere,  the  equinus 
type  of  deformity  being  three  times  as  common  as  the  calcaneus 
form. 

If  the  anterior  muscles  are  paralyzed  in  a  child  before  the 
walking  age,  the  foot  drops  under  the  influence  of  the  force  of 
gravity  into  the  attitude  of  equinus.  If  this  attitude  is  allowed 
to  persist,  the  muscles  on  the  posterior  aspect  of  the  limb,  accom- 
modating themselves  to  the  habitual  attitude,  in  time  become 
structurally  shortened.  In  such  cases  the  equinus  deformity  is 
caused  by  the  force  of  gravity  ;  it  is  increased  by  muscular  action 
and  it  is  fixed  by  muscular  adaptation.  That  deformity  is  not 
caused  directly  by  muscular  action  is  shown  by  the  fact  that  it 
may  be  prevented  by  stimulating  the  paralyzed  muscles  from 
time  to  time  with  galvanism,  or  even  by  systematic  passive 
movements  to  the  limit  of  dorsal  flexion.  Deformity  is  thus 
prevented,  not  by  opposing  muscular  action,  but  by  stretching 
the  active  muscles  to  their  full  limits  from  time  to  time,  and  thus 
preventing  muscular  adaptation  and  structural  change.  In  the 
instance  cited  gravity  and  muscular  activity  are  combined  in  the 
production  of  equinus,  but  in  other  instances  gravity  and  mus- 
cular power  may  be  opposed  to  one  another.  If,  for  example, 
the  calf  muscle  is  paralyzed  while  the  anterior  group  retains  its 
power,  the  deformity  of  calcaneus  does  not  appear  until  the  child 
begins  to  use  the  foot,  when  the  peculiar  helplessness  calls  atten- 
tion to  the  disability,  if  the  diagnosis  has  not  been  made  before. 
Thus  it  is  that  equinus  may  be  present  when  the  child  is  still  in 
arms,  while  the  opposite  deformity  develops  much  more  slowly. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


591 


FfG.  355. 


Habitual  Posture.  There  are  other  cases  in  which  every  ves- 
tige of  muscular  power  is  lost  and  in  which  the  foot  dangles. 
In  this  class  there  is  no  functional  activity  or  tonic  shortening  of 
the  muscles ;  consequently  deformity  is  slow  in  making  its  appear- 
ance ;  it  is  not  often  extreme,  and  it  becomes  fixed  only  by  the 
structural  shortening  of  the 
inactive  tissues,  the  ligaments, 
and  fasciae.  There  are,  of 
course,  other  causes  for  habit- 
ual posture  than  the  force  of 
gravity  and  muscular  action, 
such  as,  for  example,  the  posi- 
tion of  convenience  in  which 
a  weak  or  disabled  part  might 
be  placed,  but  such  causes  of 
deformity  may  be  considered 
as  instances  of  functional  use 
or  rather  of  adaptation  to  local 
weakness. 

Functional  Use  as  a  Cause  of 
Deformity.  Thus  far  the  force 
of  gravity,  unbalanced  mus- 
cular power,  and  the  struc- 
tural changes  in  the  tissues 
have  been  considered  in  the 
etiology  of  deformity,  as  it 
might  develop  in  infancy. 
When,  however,  the  patient 
stands  and  walks,  existing  de- 
formities are  exaggerated  and 
distortions  are  developed  and 
confirmed  by  the  weight  of 
the  body  falling  on  the  unbal- 
anced part,  and  by  the  action 
of  the  muscles  in  the  attempt 
to  supply  the  function  of  those 
that  are  paralyzed.  Thus  it  is 
that  the  deformity  develops  far  more  rapidly  when  a  fair  amount 
of  muscular  power  remains  than  when  it  is  completely  lost.  (See 
Talipes.) 

Subluxation.     Aside  from  the  distortions  due  to  the  causes  that 
have  been  mentioned,  there  are  others  induced   simply  by  weak- 


Anterior  poliomyelitis.  Duration  seven  years. 
Showing  atrophy  and  slight  lateral  curvature  of 
the  spine  ;  two  and  a  quarter  inches  of  shorten- 
ing. 


592  ORTHOPEDIC  SUROEBY. 

ness  ;  for  example,  when  laxity  of  ligaments  and  the  failure  of 
muscular  support  permits  distortion  of  a  limb  and  subluxation 
or  even  displacement  at  a  joint  (Figs.  356  and  357).  Complete 
displacement  is  uncommon,  and  occurs  practically  only  at  the 
hip.  In  such  cases  there  is  usually  flexion  deformity  of  the 
limb.  The  femur  is  suspended  by  the  contracted  tissues  attached 
to  the  anterior  superior  spine.  This  unyielding  band  forms  a 
fulcrum  by  means  of  which  force  applied  at  the  knee  may  cause 
sudden  displacement  of  the  head  of  the  femur  inward  or  upward 
and  backward. 

Deformities  of  the  Upper  Extremity.  Deformities  caused  by 
paralysis  of  the  muscles  of  the  shoulder  and  upper  arm  are 
usually  slight  because  the  part  is  not  subjected  to  the  strain  of 
weight  bearing,  and  because  the  force  of  gravity  is  opposed  to 
muscular  contraction.  In  these  cases  the  loss  of  support  and  the 
tension  on  the  capsule  allows  a  considerable  separation  of  the 
joint  surfaces  so  that  the  atrophied  head  of  the  humerus  may  be 
displaced  forward  or  backward  ;  but  there  is  not  often  fixed 
displacement,  and  consequently  persistent  distortion  due  to  this 
cause  is  unusual. 

Paralysis  of  the  muscles  of  the  forearm  and  of  the  hand  is  fol- 
lowed after  a  time  by  deformity  of  the  fingers,  caused  primarily 
by  unopposed  muscular  action,  secondarily  by  accommodation  and 
atrophy. 

Deformities  of  the  Neck.  Paralysis  of  one  or  more  of  the 
muscles  of  the  neck  may  induce  a  paralytic  torticollis.  This  is, 
however,  extremely  uncommon. 

Deformities  of  the  Trunk.  Paralysis  of  the  muscles  of  the  trunk 
may  induce  distortion  and  extreme  lateral  curvature  of  the  spine. 
This  curvature  is  not  usually  caused,  as  might  at  first  appear, 
by  contraction  of  the  active  muscles  and  thus  a  bending  of  the 
trunk  with  a  convexity  toward  the  weaker  side.  As  a  rule,  the 
curvature  is,  as  a  whole,  in  the  opposite  direction.  This  is 
explained  by  the  fact  that  if  the  paralysis  is  limited  to  one  side 
and  is  extensive  enough  to  cause  distortion  of  the  trunk,  the 
muscles  of  respiration  being  involved,  the  chest  wall  becomes 
inactive  and  collapses.  In  compensation  the  opposite  side  of 
the  thorax  increases  in  volume  and  lung  capacity  and  the. 
weak,  atrophied,  and  sunken  side  is  drawn  toward  it.  The 
same  effect  is  observed  when  the  arm  and  the  shoulder  mus- 
cles are  paralyzed,  the  spine  bending  toward  the  side  that  is 
still  active. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  593 

Paralysis  of  the  posterior  group  of  muscles,  if  extreme,  may 
cause  a  kyphosis.  Paralysis  of  the  muscles  of  the  abdomen  may 
induce  lordosis,  but  in  this  group  of  cases  the  lower  extremities 
are  usually  involved,  and  the  secondary  distortions  due  to  posture 
and  to  functional  use  mask  the  direct  effect  of  the  paralysis  of 
the  muscles  of  the  trunk.     And,  again,  the  overuse  of  the  arm 

Fig.  356. 


Anterior  poliomyelitis,  caubiiig  genu  recurvatum.    (See  Fig.  357.) 

muscles  in  patients  whose  lower  extremities  are  paralyzed,  and 
the  suspension  of  the  body  on  crutches  in  walking,^raodify  the 
ultimate  effects  in  those  cases  in  which  the  paralysis  is  wide- 
spread in  its  area.      (See  Ijatoral  Curvature.) 

Retardation  of  Growth  and  Secondary  Deformities.     The  effects 
of  anterior  poliomyr^litis  arc  not  limited  to  the  paralysis  and  to 

38 


594  ORTHOPEDIC  SURGERY. 

atrophy  of  the  muscles,  but  all  the  component  tissues  of  the 
affected  limb  are  involved  as  well.  The  bones  become  relatively 
atrophied,  and  their  growth  is  retarded  to  a  degree  proportionate 
to  the  extent  of  the  paralysis  and  to  the  functional  disability  that 
has  resulted.  It  has  been  stated,  however,  that  retardation  of 
growth  does  not  always  correspond  to  the  amount  of  paralysis. 
In  some  instances  paralysis  of  a  single  muscle,  which  does  not 
seriously  compromise  the  function  of  the  part,  is  attended  with 
greater  shortening  of  the  limb  than  in  other  cases  in  which  the 
paralysis  is  far  more  extensive.  Thus  it  may  be  inferred  that 
certain  cells  in  the  spinal  cord  are  especially  concerned  in  the 
growth  and  nutrition  of  the  bones,  and  that  interference  with  the 
function  of  these  cells  may  not  correspond  absolutely  to  the  extent 
of  the  destructive  process.     However  this  may  be,  it  is  certain 

Fig.  357. 


Anterior  poliomyelitis.    Paralysis  of  muscles  at  the  hip  allows  subluxation  of  the  femur. 
The  same  patient  as  in  Fig.  356. 

that  atrophy  and  retardation  of  growth  are  much  greater  when  a 
limb  is  not  used  than  when  by  the  aid  of  apparatus  it  has  been 
enabled  to  carry  out,  in  part  at  least,  its  proper  function.  It  is 
evident,  also,  that  retardation  of  growth  will  be  more  marked 
during  the  period  of  rapid  development ;  thus,  the  younger  the 
patient  the  greater  should  be  the  ultimate  inequality  of  the  limbs. 

E.ETAEDATION  OF  Growth.  The  ultimate  shortening  varies 
from  one  to  three  inches.  In  the  slighter  degrees  of  paralysis 
affecting  the  leg,  the  shortening  may  be  less  than  an  inch,  but 
when  the  thigh  muscles  are  paralyzed,  also,  it  may  be  much  more 
(Fig.  355).  This  inequality  is  usually  very  evident  in  the  size 
of  the  two  feet. 

When  both  limbs  are  paralyzed  so  that  locomotion  is  very 
seriously  interfered  with,  the  retardation  of  growth  is  especially 


DISEASES  OF  THE  NERVOUS  SYSTEM.  595 

marked,  and  the  contrast  between  the  trunk  of  the  patient  and 
the  attenuated  lower  extremities  is  very  striking. 

Secondary  deformities  must  include,  besides  those  already 
mentioned,  the  compensatory  distortions  of  the  trunk  that  may 
follow  paralysis  of  the  limbs.  Thus  a  short  leg  might  cause  a 
lateral  curvature  of  the  spine,  or  great  flexion  contraction  of  the 
thigh  might  induce  abnormal  lordosis.  As  a  matter  of  fact,  the 
final  effects  of  disabilities  of  this  character  are  very  complex,  and 
are  influenced  by  many  factors  of  which  only  a  general  indication 
is  practicable. 

Treatment.  The  treatment  of  the  acute  stage  of  anterior 
poliomyelitis  is  symptomatic.  If  the  diagnosis  has  been  made, 
such  measures  as  would  tend  to  relieve  the  congestion  about  the 
diseased  area  should  be  employed  ;  cathartics,  sedatives,  and 
counter-irritation  of  the  spine,  for  example.  When  the  acute 
symptoms  have  subsided  local  treatment  to  maintain  as  far  as 
possible  the  nutrition  of  the  muscles,  to  prevent  deformity,  and 
to  relieve  the  strain  upon  the  weakened  tissues  is  indicated.  The 
nutrition  of  the  parts  may  be  improved  by  massage,  by  muscle- 
beating,  by  the  direct  application  of  heat  to  the  cold  extremities, 
and  by  the  use  of  galvanism,  as  long  as  it  will  induce  contraction 
of  the  paralyzed  muscles. 

Deformity  may  be  prevented  by  moving  each  joint  to  the  limit 
of  the  range  of  motion  in  all  directions  several  times  a  day,  and 
by  supporting  the  limb  with  appropriate  apparatus.  Deformity 
in  those  parts  in  which  it  is  favored  by  muscular  action  and  by 
the  force  of  gravity  appears  much  more  rapidly  than  is  generally 
supposed.  The  indications  of  equinus,  for  example,  are  apparent 
within  a  few  weeks  after  paralysis  of  the  anterior  muscles  of  the 
leg.  The  first  indication  of  such  deformity  in  this  class  is  the 
discomfort  caused  by  passively  moving  the  foot  toward  dorsal 
flexion.  This  limitation  of  the  range  of  motion  rapidly  increases, 
and  as  it  increases  it  is  confirmed  by  muscular  adaptation  and 
finally  by  structural  shortening. 

The  Principles  of  Mechanical  Treatment.  The  object  of  a  brace 
is  to  prevent  the  deformity  due  to  weakness  and  to  utilize  the 
muscular  power  that  remains,  so  that  the  disabled  member  may 
carry  out  its  function.  As  each  muscle  has  an  essential  function 
the  paralysis  of  any  one  must  be  followed  by  a  certain  disability 
and  usually  l)y  deformity.  Muscles  vary  in  importance  as  they  do 
in  strength,  and  the  ultimate  disability  caused  by  paralysis  may  be 
predicted  very  accurately  by  one  who  is  familiar  with  this  function. 


596 


ORTHOPEDIC  SURGERY. 


Paralysis  of  the  Anterior  Muscles  of  the  Leg.  Par- 
alysis of  the  anterior  leg  group  causes  the  so-called  steppage  gait ; 
the  toes  drag  on  the  floor  when  the  limb  is  swung  forward,  and 
this  necessitates  an  awkward  lifting  of  the  knee.  The  result  of 
such  paralysis  is  equinus.  Slight  equinus  has  a  tendency  to 
throw  the  knee  backward,  "  recurvatum,"  in  order  that  the 
patient  may  place  the  entire  sole  on  the  ground.  More  marked 
equinus  obliges  the  patient  to  bear  the  weight  entirely  on  the 
front  of  the  foot,  and  causes  flexion  both  at  the  knee  and  hip. 
If  but  one  of  the  muscles  of  the  anterior  group  is  paralyzed  the 


Fig.  358. 


Fig.  359. 


c^ 


The  Judson  brace  for  paralysis  of  the  quadriceps  extensor  muscle  in  connection 
with  deformity  of  the  foot. 


tendency  to  equinus  is  in  so  far  lessened,  but  there  is  an  inclina- 
tion to  lateral  distortion.  Paralysis  of  the  anterior  muscles  causes 
an  awkward  gait  and  often  deformity,  but  the  propelling  force  of 
the  limb  remains.  The  indication  for  support  is  simple,  to  pre- 
vent the  foot  from  dropping  to  the  extent  that  incommodes  the 
patient,  or  practically  to  hold  the  foot  at  a  right  angle  with  the 
leg. 

Paralysis  of  the  Posterior  Muscles  of  the  Leg.  If, 
on  the  other  hand,  the  calf  muscles  are  paralyzed  the  resistance 
of  the  foot  is  lost  and  it  is  simply  dorsiflexed  when  weight  is 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


597 


thrown  upon  it.  Thus  the  brace  must  be  arranged  to  prevent 
dorsal  flexion,  and  it  must  be  strong  enough  to  support  the  strain 
which  is  transmitted  from  the  foot  plate  of  the  brace  to  the  front 
of  the  leg.     The  various  weaknesses  and  deformities  of  the  foot 


Fig.  360. 


A  brace  for  complete  paralysis  of  tbe 
limb,  showing  a  form  of  lock  at  tlie 
knee  and  a  limited  joint  at  the  ankle. 


Anterior  poliomyelitis.  Paralysi.s  of  the 
anterior  and  posterior  muscles.  Recurva- 
tion of  the  right  knee. 


and  the  means  of  treating  tlicm  arc  described  at  length  elsewhere. 
(See  Talipes.) 

Paralysis  of  the  culf  muscles  not  only  affects  the  foot,  but  it 
weakens   the   knee   as   well,   and    genu    recurvatum   is  often   a 


598  ORTHOPEDIC  SURGERY. 

secondary  effect.  In  many  instances,  therefore,  it  will  be  neces- 
sary to  support  the  knee  as  well  as  the  ankle  during  the  earlier 
stages  of  the  treatment. 

Paralysis  of  the  Thigh  Muscles.  Paralysis  of  the  quad- 
riceps extensor  muscle  causes  primarily  a  peculiar  gait.  The 
patient,  unable  to  extend  the  leg  upon  the  thigh,  throws  or 
swings  it  forward,  then  locks  the  joint  by  direct  contact  of  the 
bones  and  by  the  resistance  of  the  posterior  tissues,  by  inclining 
the  body  somewhat  forward  as  the  weight  falls  upon  it.  In  this 
manner,  again,  the  knee  may  be  overextended.  Or  if  extension 
is  checked  by  shortening  of  the  tissues,  induced  possibly  by 
habitual  assumption  of  the  sitting  posture,  the  patient  being 
unable  to  lock  the  joint  effectively  by  complete  contact  of  the 
bones,  often  trips  and  falls  because  of  the  insecurity  of  the  sup- 
port. When  in  the  normal  subject  the  weight  is  borne  upon  one 
limb  in  the  attitude  of  rest,  in  which  the  muscles  are  thrown  out 
of  action,  the  knee-joint  is  locked,  but  the  insecurity  of  this  sup- 
port is  illustrated  by  the  school-boy's  trick  of  striking  the  back 
of  the  knee  with  the  hand,  when,  the  muscles  being  taken 
unawares,  the  person  falls  to  the  ground.  This  insecurity  is 
constant  when  the  extensor  of  the  leg  is  paralyzed. 

Paralysis  limited  to  the  quadriceps  extensor  muscle  is,  how- 
ever, very  unusual.  In  almost  all  cases  some  of  the  leg  muscles 
are  involved  also,  and  the  brace  usually  must  serve  to  support 
the  foot  as  well  as  the  knee.  In  its  ordinary  form  such  a  brace 
is  constructed  of  two  lateral  upright  bars,  reaching  nearly  to  the 
pubes  on  the  inner  and  to  the  trochanter  on  the  outer  side,  joined 
to  one  another  by  bands  passing  beneath  the  thigh  and  the  calf, 
and  attached  to  a  light  steel  foot  plate.  If  the  dorsal  flexors  of 
the  foot  are  paralyzed  the  ankle-joint  is  arranged  to  allow  dorsal 
flexion,  but  to  prevent  extension  beyond  the  right  angle.  If  the 
calf  muscle  is  paralyzed  a  reverse  catch  is  used,  or  the  uprights 
are  attached  directly  to  the  foot  plate  without  a  joint  (Fig.  359)  ; 
or  the  so-called  limit  joint,  allowing  only  a  few  degrees  of  motion 
in  either  direction,  is  used  (Fig.  360).  (See  Talipes.)  In  the 
treatment  of  young  children  the  joint  is  also  omitted  at  the  knee, 
the  limb  being  firmly  held  in  the  extended  position  during  the 
active  period  (Figs.  359  and  362).  This  is  of  advantage  because 
the  joint  is  the  weakest  part  of  the  brace  and  it  soon  becomes  loose 
under  the  severe  strain  to  which  it  is  subjected.  In  older  sub- 
jects a  joint  is  arranged  with  a  spring  catch,  the  brace  being  held 
in  the  straight  position  when  the  patient  is  walking  about,  but 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


599 


allowing  flexion  when  the  sitting  posture  is  assumed.  This  is, 
of  course,  a  great  convenience  (Fig.  360).  In  fitting  the  brace 
the  lateral  bars  should  be  adjusted  to  support  the  limb  without 
uncomfortable  pressure,  and  the  joints  should  be  exactly  opposite 
the  normal  centres  of  motion.  The  thigh  and  leg  bands  should 
be  properly  fitted  to  the  contour  of  the  soft  parts  so  that  haK 
the  limb  is  contained  within  them.  These  are  smoothly  covered 
with  leather,  and  the  limb  is  held  in  position  by  leather  bands 


Fig.  362. 


Brace  for  complete  paralysis  of  the  anterior  muscles  of  the  limb ;  belore  and  after  covering. 


that  complete  the  circumference.  Other  bands  are  applied  across 
the  front  or  back  of  the  limb,  either  to  support  it  or  to  fix  it 
firmly  in  place.  In  the  ordinary  brace  without  the  joint  at  the 
knee  there  are  three  anterior  l)ands,  one  across  the  front  of  the 
thigh,  another  across  the  leg,  and  the  third,  a  wide  knee-cap, 
supports  the  greater  part  of  the  strain  (Fig.  362). 

Pauai>y.sih  of  the  Muscleh  of  the  ITif.     The  effect  of 
paralysis  of  tlu^  niiiH(;K's  about  the  hip   is  difficult  to  describe,  as 


600  ORTHOPEDIC  S UBGEB  Y. 

in  these  cases  many  other  muscles  are  usually  involved.  If  all 
the  muscles  are  paralyzed  the  thigh  dangles.  This  is,  however, 
very  unusual,  for  the  tensor  vaginse  feraoris  almost  always 
retains  its  power  and  is  one  of  the  causes  of  flexion  deformity 
which  is  so  often  present  in  cases  of  this  character. 

Paralysis  of  the  iliopsoas  muscle  makes  it  impossible  for  the 
patient  to  flex  the  thigh  directly.  If  the  adductors  are  paralyzed 
he  must  lift  the  thigh  with  the  hand  when  adduction  is  desired. 
Paralysis  of  the  glutei  is  made  evident  by  the  atrophy  and  by  the 
weakness  of  the  extendiag  power  of  the  limb. 

The  distribution  of  the  paralysis  of  the  muscles  of  the  hip  may 
be  ascertained  by  placing  the  patient  in  the  recumbent  posture ; 
the  leg  is  then  lifted  from  the  table,  and  by  placing  the  thigh  in 
different  positions  the  ability  of  the  patient  to  move  it  may  be 
tested,  in  older  subjects  by  voluntary  effort,  in  younger  ones  by 
pricking  the  part  slightly  with  a  pin. 

General  weakness  of  the  muscles  of  the  hip  causes  an  awkward, 
insecure  gait,  accompanied  usually  by  outward  rotation  of  the 
limb,  and,  as  has  been  stated,  there  is  almost  always  accompany- 
ing paralysis  of  other  muscles  of  the  extremity.  In  such  cases  a 
pelvic  band  must  be  attached  to  the  leg  brace.  The  pelvic  band 
is  made  of  sheet  steel  of  about  18  gauge,  two  inches  wide,  fitted 
to  the  pelvis,  which  it  encircles  midway  between  the  crest  of  the 
ilium  and  the  trochanter.  At  this  point  it  is  attached  to  the  brace 
by  a  free  joint  (Fig.  363).  When  the  band  is  accurately  adjusted 
and  strapped  firmly  about  the  pelvis,  the  necessary  security  is 
assured  and  the  attitude  of  the  limb  in  walking  can  be  regulated. 
If  greater  support  is  desired  a  perineal  band  may  be  applied  as 
described  in  the  chapter  on  disease  of  the  hip-joint. 

If  both  limbs  are  paralyzed  double  braces  must  be  used.  If 
the  muscles  of  the  lower  part  of  the  back  are  much  weakened 
the  pelvic  baud  may  be  replaced  by  a  corset  or  some  form  of 
back  brace.     Fortunately  these  cases  are  uncommon. 

Paralytic  Scoliosis.  Paralytic  scoliosis  requires  the  sup- 
port of  corsets  or  braces  as  a  rule,  such  as  are  used  in  the 
treatment  of  other  forms  of  distortion  of  the  back.  (See  Lateral 
Curvature.) 

Paralysis  of  the  Arm.  Paralysis  of  the  arm  is  uncommon, 
and  treatment  is  rarely  demanded. 

In  some  instances  a  shoulder  support  may  be  of  service  or  a 
brace  to  hold  the  arm  at  a  right  angle  if  the  biceps  is  paralyzed. 
If  the  muscles  of  the  scapula  retain  their  power  the  operation  of 


DISEASES  OF  THE  NERVOUS  SYSTEM.  601 

arthrodesis  might  be  of  service  in  fixing  the  dangling  joint,  and 
the  same  operation  might  be  useful  at  the  elbow.  It  is,  of  course, 
evident  that  one  of  the  lower  extremities,  although  hopelessly- 
weakened,  may  be  braced  so  that  it  may  serve  as  a  simple  prop 
to  bear  weight,  but  as  the  function  of  the  arm  is  quite  different, 
extensive  paralysis  of  its  muscles  makes  it  practically  useless  to 
the  individual. 

Operative  Treatment.  The  Reduction  of  Deformity.  In 
a  large  proportion  of  the  cases  of  anterior  poliomyelitis  the 
patients  are  not  seen  by  the  orthopedic  surgeon  until  months  or 
years  have  elapsed  since  the  original  attack.  They  are  then 
brought  for  treatment  because  of  secondary  deformity  often  of  an 
extreme  degree.  At  least  half  of  the  cases  of  talipes  are  due  to 
this  cause,  and  with  the  deformity  of  the  foot  are  often  combined 
other  distortions  varying  in  degree  with  the  extent  of  the 
paralysis.  Many  of  the  patients  hobble  about  on  a  distorted  foot, 
others  use  crutches,  and  in  a  smaller  number  the  only  method  of 
locomotion  is  creeping  on  all-fours.  In  the  cases  in  which  the 
patient  has  habitually  used  crutches  allowing  the  paralyzed  limb 
to  "  dangle,"  there  is  usually  marked  flexion  at  the  three  joints. 
The  thigh  is  flexed  upon  the  pelvis,  the  leg  is  flexed  upon  the 
thigh,  and  the  foot  hangs  downward  and  inward  (plantar  flexed) 
in  an  attitude  of  equino  varus. 

However  extreme  the  paralysis  of  a  lower  extremity  may  be, 
the  limb  may  be  made  useful  as  a  prop  when  properly  braced ; 
this  prop  will  enable  the  patient  to  dispense  with  the  use  of 
crutches  and  thus  free  the  arms  from  unnecessary  work.  Even 
if  both  limbs  are  paralyzed  they  may  at  least  serve  as  supports  to 
enable  the  patient  to  stand  erect  and  to  propel  himself  with  the 
aid  of  crutches.  If  a  limb  has  been  disused  for  a  long  time, 
the  atrophy  is  usually  extreme,  the  bones  are  fragile,  and  the 
growth  has  been  greatly  retarded  as  compared  with  those  limbs 
in  which  deformity  has  been  prevented  and  in  which  the  weight 
of  the  body  has  been  sustained  in  functional  use.  In  this  class 
of  cases  the  first  step  must  be  the  reduction  of  deformity ;  the 
foot  must  be  brought  to  a  right  angle  with  the  leg,  the  limb  must 
be  brought  to  the  straight  line,  and  the  flexion  at  the  hip  must  be 
overcome  in  order  to  enable  the  patient  to  stand  erect  without 
bending  the  spine  forward  in  compensatory  lordosis. 

Acquired  deformity  of  the  foot  is  far  less  resistant  than  is  the 
congenital  form,  and  by  tenotomy  and  the  proper  application  of 
force  it  may  be  readily  straightened,  usually  at  one  sitting. 


602  OB THOPEDIC  SUBGER  Y. 

The  flexion  contraction  at  the  knee  may  be  overcome  also  by 
careful  and  persistent  manual  stretching  combined,  if  necessary, 
with  division  of  the  contracted  tissues  on  the  posterior  aspect  of 
the  joint.      (See  page  412.) 

The  flexion  deformity  at  the  hip  is  usually  fixed  by  the  con- 
traction of  the  tissues  about  the  anterior  superior  spine  of  the 
ilium,  including  the  tensor  vaginae  femoris  muscle,  which  is  rarely 
paralyzed.  These  tissues,  together  with  the  fascia,  may  be  divided 
subcutaneously,  or  by  open  incision,  if  necessary  ;  after  which 
the  deformity  may  be  reduced  by  gradual  forcible  extension  of  the 
thigh  while  the  pelvis  is  fixed  by  flexing  the  other  limb  upon  the 
body.  When  the  contraction  deformities  are  overcome  lateral 
deviation  at  the  knee  is  corrected,  if  it  be  present,  in  the  same 
manner,  and  the  bony  points  having  been  carefully  protected  by 
padding  a  long  spica  plaster  bandage  is  applied  to  fix  the  limb. 

The  lesser  degrees  of  deformity  may  be  reduced  by  other 
means,  for  example,  by  repeated  applications  of  plaster  bandages 
under  slight  corrective  force,  or  by  manipulation,  or  by  braces 
and  bandaging. 

Paralytic  knock-knee  may  be  corrected  by  the  Thomas  knock- 
knee  brace,  and  this  brace  when  attached  to  a  pelvic  band  is  a 
useful  form  of  support  in  the  routine  treatment  of  paralysis  of 
the  leg  (Fig.  339). 

The  Thomas  caliper  knee  brace  is  another  cheap  and  useful 
support.  It  is  of  especial  service  when  there  is  flexion  or  lateral 
deformity  of  the  limb  (Fig.  259). 

When  distortion  has  been  overcome  and  when  functional  use 
has  been  made  possible  by  proper  support,  the  development  of 
active  muscles  which  have  been  thrown  out  of  use  by  the  distor- 
tions, and  of  those  in  which  part  of  the  muscular  substance  has 
been  retained,  is  surprising.  In  many  of  these  cases  the  distor- 
tions which  developed  during  the  temporary  paralysis  have  alone 
prevented  recovery,  and  this  latent  power  may  be  revived  even 
after  years  of  disuse.  Thus  in  many  instances  prognosis  is 
impossible  until  the  deformities  have  been  corrected  and  until  the 
limb,  properly  supported,  has  been  enabled  to  resume  its  function. 

Tendon  Transplantation.  This  operation  is  best  adapted 
to  the  treatment  of  distortions  of  the  foot  caused  by  paralysis  of 
the  muscles  of  the  leg,  and  the  procedure  is  described  at  length 
in  that  section. 

Paralysis  of  the  muscles  of  the  arm  and  hand  is  unusual.  The 
operation  of  tendon  shortening  combined  with  transplantation  of 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


603 


the  tendons  of  one  or  more  active  muscles  may  be  of  service  in 
the  treatment  of  wrist-drop,  and  opportunities  may  suggest  them- 
selves in  other  situations  whenever  it  is  possible  to  utilize  the 
muscular  power  to  better  advantage. 

Arthrodesis.     As  has  been  stated  of  tendon  transplantation, 
arthrodesis  is  of  greatest  service  at  the  ankle-joint,  where  it  may 

Fig.  363. 


Leg  brace,  with  pelvic  band.    Double  uprights.    No  joint  at  knee.    For  paralysis 
of  the  anterior  thigh  and  leg  muscles. 

serve  to  fix  the  foot  at  a  right  angle  with  the  leg.  (See  Talipes.) 
In  exceptional  cases  arthrodesis  or  excision  at  the  knee  may  be 
advisable  in  the  older  patients,  but  in  young  subjects  the  strain 
U])on  the  long,  weak  lever  formed  by  the  two  bones  will  almost 
always   induce  deformity.     Arthrodesis  at  the  hip  might  be  of 


604  ORTHOPEDIC  SURGERY. 

service  in  complete  paralysis  of  the  pelvic  muscles^  at  the  shoulder 
when  the  muscles  attached  to  the  scapula  are  active,  and  in 
exceptional  cases  at  the  elbow  and  wrist  to  assure  an  improved 
position.     The  operation  is  described  elsewhere. 

Osteotomy.  In  rare  instances,  particularly  in  the  extreme 
deformities  in  the  adult,  osteotomy  of  the  femur  at  the  hip  or 
knee  may  be  necessary  in  order  to  overcome  resistant  distortion. 

Recapitulation  of  Treatment.  This  consists  in  support  and 
electrical  stimulation  of  the  muscles  during  the  period  of  recov- 
ery, together  with  a  suitable  brace  to  hold  the  limb  in  the  best 
possible  position  for  usefulness  when  the  final  extent  of  the 
paralysis  has  become  evident.  With  the  support  any  treatment 
that  will  improve  the  nutrition  of  the  part  is  of  service ;  massage 
and  muscle  beating  are  of  especial  value.  The  limb  in  which 
the  circulation  is  deficient  should  be  protected  from  the  cold  by 
proper  covering,  and  its  nutrition  may  be  improved  by  the  direct 
application  of  heat,  the  hot-air  or  hot-water  bath  both  being 
useful.  Above  all  else,  functional  use,  which  is  made  possible 
by  apparatus,  is  of  the  first  importance  in  preserving  and  stimu- 
lating whatever  muscular  power  remains  ;  and  special  gymnastic 
exercises  to  this  end  may  be  employed  if  practicable.  The  pre- 
vention of  deformity  during  the  growing  period  is  of  great 
importance.  Every  morning  and  night  the  joints  of  the  paralyzed 
part  should  be  passively  moved  to  the  normal  limits  in  all  direc- 
tions in  order  to  prevent  the  gradual  limitation  of  the  range  of 
motion  which  is  the  first  indication  of  the  deformity.  Lateral 
deviation  of  the  limb  or  foot  may  be  prevented  by  passive 
manipulation  and  by  careful  adjustment  or  modification  of  the 
support.  Braces  should  be  strong,  and  as  simple  as  may  be 
in  construction.  Elastic  bands^'and  springs,  applied  with  the 
design  of  replacing  paralyzed  muscles,  are  of  little  practical  use, 
since  they  are  ineffective  in  action,  difficult  to  adjust,  and  easily 
disarranged.  The  parent,  when  treatment  is  begun,  must  be 
impressed  with  the  fact  that  a  brace  must  be  strong  enough 
to  serve  its  purpose  even  though  its  weight  be  objectionable ; 
that  its  period  of  usefulness  is  limited,  and  that  it  must  be 
replaced  when  it  is  outgrown ;  that  the  breaking  of  a  brace 
from  time  to  time  is  unavoidable,  and  that  such  accidents,  in  so 
far  as  they  are  evidences  of  the  functional  activity  of  the  patient, 
are  favorable  indications. 

Careful  supervision  of  the  patient,  even  though  the  weakness 
is  not  great,  will  be  necessary  during  the  period  of  growth.     The 


DISEASES  OF  THE  NERVOUS  SYSTEM.  605 

contrast  between  the  development  and  symmetry,  the  muscular 
power  and  practical  utility  of  a  limb  that  has  received  this  care 
and  supervision,  and  one  that  has  been  neglected,  is  sufficiently 
striking  to  impress  anyone  with  the  necessity  for  this  tedious 
and  apparently  never-ending  treatment. 

Thus,  in  this  as  in  other  chronic  diseases  and  disabilities,  the 
character  and  the  duration  of  the  treatment,  its  object,  and  the 
final  results  that  one  may  expect  to  attain  by  it  should  be 
explained  to  the  parents  when  the  care  of  the  patient  is  under- 
taken. 


CHAPTER   XYIII. 

DISEASES  OF  THE  NERVOUS  SYSTEM  (Continued). 

Cerebral  Paralysis  of  Childhood— Spastic  Paralysis. 

Cerebral  paralysis  or  palsy  is  in  orthopedic  practice  second 
only  in  frequency  and  importance  to  anterior  poliomyelitis.  It 
is,  however,  entirely  different  in  its  distribution  and  in  its  effects. 
It  is  a  form  of  disability  that  is  characterized  by  motor  weakness, 
by  stiffness  and  loss  of  control,  rather  than  by  paralysis.  It 
affects  entire  members  and  it  results  in  atrophy,  contractions,  and 
deformity. 

It  may  involve  half  the  body,  hemiplegia. 

It  may  be  limited  to  the  lower  extremities,  paraplegia. 

It  may  involve  both  the  upper  and  lower  extremities,  diplegia. 

In  rare  instances  but  one  extremity  is  affected,  monoplegia. 

Distribution.  In  451  cases  of  cerebral  paralysis  analyzed  by 
Peterson,^  332  were  of  the  hemiplegic  type,  73  were  of  the 
diplegic  type,  and  46  were  of  the  paraplegic  type.  In  121  cases 
observed  at  the  Hospital  for  Ruptured  and  Crippled,  63  were 
paraplegic  or  diplegic  and  58  were  hemiplegic.  The  hemiplegic 
form  of  paralysis  is  usually  acquired  ;  the  diplegic  and  paraplegic 
forms  are  usually  congenital. 

Etiology  and  Pathology.  Cerebral  paralysis  may  be  divided 
into  two  classes — the  congenital  and  the  acquired. 

Congenital  Paralysis.  Paralysis  of  intra-uterine  origin  may  be 
the  result  of  maldevelopment  or  injury  or  a  secondary  effect  of 
intercurrent  disease  of  the  mother.  Paralysis  caused  by  injury 
at  birth  is  usually  the  result  of  rupture  of  bloodvessels  of  the 
meninges  due  to  prolonged  labor  or  to  the  pressure  of  instru- 
ments. 

Acquired  Paralysis.  Acquired  paralysis  may  be  due  to  hemor- 
rhage, embolism,  thrombosis,  or  to  disease.  Sachs^  presents  the 
following  classification  of  causes  and  effects  : 


1  American  Text-book  of  Diseases  of  Children. 

2  Sachs.    The  Nervous  Diseases  of  Children. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


607 


Paealysis  of  Intea-uterine  Origin. 

Large  cerebral  defects — true  porencephaly. 

Hemorrhages  of  intra-uterine  origin — softening. 

Agenesis  cortical  is. 
Paralysis  Occurring  during  Labor. 

Meningeal  hemorrhage — very  seldom  intracerebral.  Result- 
ing conditions  :  meningo-encephalitis  chronica  ;  sclerosis  ;  cysts  ; 
atrophies  ;  porencephalies. 


Fig.  364. 


Congenital  cerebral  diplegia.    Idiocy. 

Paralysis  Acquired  after  Birth. 

1.  Meningeal  hemorrhage — very  seldom  intracerebral.  Em- 
bolism :  thrombosis  in  marantic  conditions,  and  occasionally  from 
syphilitic  endoarteritis.  Results  of  these  vascular  lesions  :  cysts  ; 
softening;  atrophy  ;  sclerosis,  diffuse  and  lobar. 

2.  Chronic  meningitis. 

3.  Hydrocephalus. 

4.  Primary  encephalitis  (Striimpell). 


608 


ORTHOPEDIC  SURGERY. 


General  Symptoms.  Motor.  The  effect  of  the  lesion  of  the 
brain  and  of  the  secondary  changes  in  the  cord  is  to  impair  the 
voluntary  control  of  the  limbs  supplied  from  the  affected  area, 
and  at  the  same  time  the  inhibition  of  the  higher  centres  is 
impaired  or  lost.  Thus,  together  with  the  loss  of  power,  there  is 
usually  a  corresponding  exaggeration  of  the  reflexes  causing  a 


Fig.  365. 


Spastic  paraplegia. 


spastic  rigidity  of  the  limbs.  This  induces  distortion,  which 
finally  becomes  fixed  by  the  adaptive  changes  in  the  tissues.  As 
the  centres  for  the  nutrition  of  the  paralyzed  parts  are  not  in- 
volved, the  muscles  do  not  waste  and  the  circulation  is  but  little 
affected.  Thus  the  atrophy  as  compared  with  paralysis  of  spinal 
origin  (anterior  poliomyelitis)  is  comparatively  slight,  and  this, 
together  with  the  loss  of  growth,  is  due  rather  to  the  general 


DISEASES  OF  THE  NERVOUS  SYSTEM.  609 

effects  of  the  disease  and  to  the  loss  of  function  than  to  the 
direct  influence  of  the  nervous  lesion. 

Mental.  In  this  form  of  paralysis  the  lesion  is  of  the  brain, 
and  the  direct  injury  of  its  structure  and  the  interference  with  its 
development  is  likely  to  cause  mental  impairment.  This  mental 
impairment  is  usually  more  marked  in  the  paraplegic  or  diplegic 
than  in  the  hemiplegic  form,  because  in  the  latter  but  half  the 
brain  is  involved,  and  because  the  injury  or  disease  occurs  at  a 
later  period  of  its  development.  So,  also,  the  mental  development 
is  usually  less  interfered  with  in  the  paraplegic  than  in  the 
diplegic  type.  For,  although  both  hemispheres  were  originally 
in  all  probability  involved,  yet  the  recovery  of  power  in  the 
arms  shows  that  the  injury  was  less  extensive  than  when  the 
weakness  persists  in  one  or  both  of  the  upper  extremities. 

It  is  estimated  that  in  50  per  cent,  of  the  hemiplegic  cases  the 
patients  are  feeble-minded,  although  comparatively  few  (13  per 
cent.)  are  idiotic.  In  the  paraplegic  and  diplegic  forms  of 
paralysis  about  70  per  cent,  of  the  patients  are  feeble-minded, 
and  from  40  to  50  per  cent,  are  idiotic.      (Sachs.) 

Epilepsy  is  an  accompaniment  of  about  45  per  cent,  of  all 
forms  of  cerebral  paralysis,  and  in  20  per  cent,  of  the  cases 
athetoid  or  associated  movements  in  the  paralyzed  parts  persist. 
(Peterson.) 

Congenital  Weakness  and  Paralysis. 

The  congenital  form  of  cerebral  paralysis  is  often  seen  in 
orthopedic  clinics,  because  the  effect  of  the  lesion  of  the  brain 
in  retarding  both  the  mental  and  physical  development  first 
attracts  the  attention  of  the  mother.  Thus,  infants  are  brought 
for  examination  because  they  are  unable  to  sit  or  stand  or  to  talk 
at  the  usual  time.  In  certain  instances  the  cause  of  the  physical 
weakness  is  simple  idiocy.  In  such  cases  the  vacant  expression, 
the  inability  of  the  child  to  recognize  even  its  mother,  the  extreme 
weakness,  and  the  absence  of  the  spastic  rigidity  of  the  limbs  will 
make  the  diagnosis  clear. 

In  another  class  of  cases  the  weakness  appears  to  be  caused 
simply  by  retarded  cerebral  development.  The  patient  is 
apathetic  and  weak.  In  these  cases,  also,  there  is  no  evidence 
of  paralysis,  and  the  evident  intelligence  of  the  patient  distin- 
guishes this  typo  frotri  the  idiotic  class. 

In  the  cliaruct(!riHti(!  form  of  cerebral  paralysis  as  seen  in  early 
life  th(;  child   may  he  idioti<t,  or  simply  apathetic,  or  apparently 

39 


610 


ORTHOPEDIC  SURGEBY. 


Fig.  36fi. 


normal  in  intelligence,  but  it  is  always  weak,  and  in  the  sitting 
posture  the  spine  is  usually  bent  backward  into  a  long,  more  or 
less  rigid  curve.  It  makes  no  effort  to  stand,  and  when  placed 
in  the  erect  posture  it  will  be  noticed  that  the  thighs  are  usually 
pressed  closely  against  one  another  and  that  the  feet  are  extended. 
The  limbs  are  "  stiff."     There  is  a  peculiar  resistance  to  flexion 

at  the  extended  joints,  which  slowly 
gives  way  under  steady  pressure. 
This  is  the  characteristic  spastic 
rigidity  (Fig.   364). 

Deformities.  These  children 
usually  begin  to  stand  and  to  walk 
at  about  the  third  year  or  later  with 
an  awkward,  shuffling  gait ;  the 
limbs  are  usually  flexed,  adducted, 
and  rotated  inward ;  the  knees  touch 
one  another  or  the  legs  may  be 
crossed,  while  the  feet  turn  inward 
in  a  persistent  attitude  of  slight 
equinovarus.  The  equilibrium  is 
very  easily  disturbed,  partly  because 
of  the  deformities  and  partly  be- 
cause of  direct  lesion  of  the  brain. 
In  the  majority  of  the  congenital 
cases  the  paralysis  is  paraplegic  in 
its  distribution  ;  perhaps  15  per  cent, 
are  of  the  hemiplegic  variety,  and  in 
a  somewhat  larger  number  the  par- 
alysis is  diplegic  in  distribution 
(Fig.  364). 

It  has  been  stated  that  the  typical 
deformity  of  the  foot  was  equino- 
varus, but  in  older  subjects  who 
have  walked  about  in  the  attitude 
of  flexion  at  the  hips  and  knees  there 
may  be  an  accommodative  distor- 
tion of  the  foot  toward  valgus,  or  even  to  an  extreme  degree 
of  calcaneovalgus. 

As  has  been  stated,  in  a  certain  number  of  cases  the  intelli- 
gence is  not  impaired,  but  more  often  the  patients  are  distinctly 
feeble-minded.  They  are  very  nervous,  easily  startled,  emotional, 
and  are  often  unable  to  speak  distinctly,  yet  it  is  interesting  to 


Acquired  cerebral  hemiplegia. 


DISEASES  OF  THE  NEB  VO  US  S  YSTEM.  611 

note  that  this  peculiar  emotional  excitability  often  passes  for  an 
extreme  degree  of  brightness  of  intellect  and  quickness  of  per- 
ception. In  fact,  parents  often  remain  unconvinced  that  the 
child  is  lacking  in  mental  power  until  it  reaches  an  age  when 
comparison  with  other  children  makes  this  conclusion  inevitable. 

Acquired  Paralysis. 

As  in  adult  life,  the  common  form  of  acquired  cerebral  par- 
alysis in  childhood  is  hemiplegia.  About  two-thirds  of  all  the 
cases  occur  in  the  first  three  years  of  life  ;  and  in  about  20  per 
cent,  of  these  the  affection  of  the  brain  is  a  complication  of  infec- 
tious disease.  The  onset  is  usually  sudden,  and  is  accompanied 
in  the  majority  of  cases  by  fever,  convulsions,  and  loss  of  con- 
sciousness. When  the  child  regains  consciousness  the  paralysis 
of  the  arm  and  leg  is  at  once  evident,  and  in  about  20  per  cent, 
of  the  cases  the  face  is  paralyzed  also. 

Deformities.  At  first  the  paralysis  is  a  simple  powerlessness, 
but  soon  the  exaggeration  of  the  reflexes  is  evident.  As  has 
been  stated,  there  is  a  loss  of  voluntary  power  and  an  increase  of 
the  reflexes  or  '^stiffness"  of  the  paralyzed  members.  They  are 
no  longer  competent  to  assume  the  more  difficult  attitudes  and 
functions,  and  these  are  replaced  by  those  that  are  simpler;  thus 
flexion  becomes  habitual. 

In  typical  hemiplegia  the  foot  is  plantar  flexed  and  adducted. 
The  leg  is  flexed  on  the  thigh  and  the  thigh  on  the  trunk,  and 
with  the  flexion  adduction  is  usually  combined.  The  arm  is  held 
against  the  thorax,  the  forearm  is  flexed  upon  the  arm  in  an  atti- 
tude midway  between  pronation  and  supination.  The  hand  is 
flexed  upon  the  arm  and  inclined  toward  the  ulnar  side  and  the 
fingers  are  clasped  over  the  adducted  thumb  (Fig.  366). 

Disability.  The  loss  of  power  is  not  absolute;  in  most 
instances  the  patient  is  able  to  walk  with  an  exaggerated  limp, 
dragging  the  stiffened  and  distorted  limb,  which  serves  as  a  prop 
rather  than  as  an  active  support.  So,  also,  the  control  of  the 
upper  extremities  is  in  part  retained ;  the  patient  is  able  to  abduct 
the  arm,  to  partly  extend  the  forearm,  sometimes  to  extend  the 
fingers  and  to  abduct  the  thumb,  but  the  power  to  dorsiflex  the 
hand  and  at  the  same  time  to  extend  the  fingers  is  not  usually 
retained  in  a  case  of  this  character. 

Loss  of  Growth.  The  growtli  of  the  patient  as  a  whole  is 
usually  retarded  to  a  certain    extent  })y  the  lesion  of  the  brain. 


612  OB  THOPEDIC  S  UR  GEB  Y. 

There  is  in  addition  a  certain  degree  of  inequality  in  the  growth 
of  the  two  halves  of  the  body.  This  inequality  is  more  marked 
in  the  upper  than  in  the  lower  extremity.  Shortening  to  the 
extent  of  an  inch  in  the  lower  extremity  is  not  usually  exceeded, 
but  the  growth  of  the  arm  and  hand  may  be  very  markedly 
checked.  This  disproportionate  loss  of  growth  in  the  upper  over 
the  lower  extremity,  although  it  may  be  explained  in  part  by 
the  situation  of  the  lesion  of  the  brain,  depends  more  directly 
upon  the  interference  with  function.  The  lower  extremity  is 
rarely  disabled  to  an  extent  that  prevents  its  use  in  locomotion, 
consequently  its  nutrition  is  preserved;  whereas  the  same  degree 
of  paralysis  of  the  arm  utterly  unfits  it  for  its  more  difficult  func- 
tions and  it  becomes  a  useless  appendage.  With  the  disuse  of 
function  there  is  a  corresponding  diminution  of  nutrition  and  a 
consequent  atrophy  and  loss  of  growth. 

Extreme  deformity  and  disability,  as  in  the  type  described,  is 
rather  unusual.  In  many  instances  there  is  almost  complete 
recovery  from  the  paralysis,  only  an  awkwardness  and  slowness 
of  movement,  combined  with  an  increase  of  reflexes  and  a  slight 
hemiatrophy  of  the  body  exists.  In  some  cases  a  slight  degree 
of  equinus  is  the  only  deformity  ;  in  others  weakness  of  the  arm 
may  persist,  although  complete  control  of  the  lower  extremities 
has  been  regained. 

The  final  effect  of  the  paralysis  is  almost  always  more  marked 
in  the  upper  than  in  the  lower  extremity  ;  thus,  when  contrac- 
tions and  deformities  of  the  lower  extremity  are  present  the  arm 
and  hand  are  often  practically  disabled. 

Treatment.  1.  Hemiplegia.  The  treatment  from  the  ortho- 
pedic standpoint  consists  in  stimulating  the  nutrition  of  the 
paralyzed  parts,  in  preventing  deformity,  and  in  improving  the 
functional  ability.  The  results  of  treatment  are,  of  course,  very 
greatly  influenced  by  the  mental  condition  of  the  patient.  If 
the  mental  power  is  not  impaired  one  may  count  upon  the  efforts 
of  the  patient  to  aid  the  surgeon  ;  whereas,  if  the  patient  is  idiotic 
there  is  but  little  encouragement  for  active  treatment.  If  the 
patient  is  seen  before  the  secondary  contractions  have  appeared, 
deformity  may  be  prevented  in  great  degree  by  regular  massage 
and  by  passive  movements  in  the  directions  opposed  to  the  habitual 
positions.  If  the  spastic  contraction  is  slight  the  control  of  the 
movements  of  the  leg  may  be  made  easier  by  the  use  of  a  light 
jointed  leg  brace  attached  to  a  pelvic  band.  By  this  means  the 
movements   are    controlled    and  the    excessive    expenditure    of 


DISEASES  OF  THE  NERVOUS  SYSTEM.  613 

nervous  energy  necessary  to  guide  the  limb  may  be  lessened. 
This  support  should  be  supplemented  by  massage  and  exercise, 
and  in  the  milder  type  of  paralysis  the  control  of  the  limb  may 
be  greatly  improved. 

In  many  instances  the  patients  are  not  seen  until  late  child- 
hood, when  the  deformities  have  become  fixed.  The  foot  is 
usually  turned  inward  and  downward  (equino varus)  ;  there  is 
flexion  at  the  knee  and  often  flexion  and  adduction  at  the  hip, 
the  resistance  of  the  contractions  being  dependent  upon  the  dura- 
tion of  the  deformity.  In  such  cases  the  distortions  must  be 
corrected  by  force  and  by  division  of  more  resistant  tissues, 
including  often  the  tendo  Achillis,  the  plantar  fascia,  and  in 
many  instances  the  hamstrings  and  the  adductors  of  the  hip. 
The  limb  is  then  fixed  in  a  plaster-of-Paris  bandage  for  a  suffi- 
cient time  to  overcome  the  more  direct  tendency  to  deformity. 
When  the  bandage  is  removed  a  brace  is  of  service  in  guiding 
the  limb,  and  regular  massage  and  forcible  passive  movements 
together  with  proper  exercises  should  be  employed  whenever 
practicable.  In  this  class  of  cases  the  deformities  may  be  over- 
come in  most  instances,  but  there  is  a  tendency  toward  flexion  at 
the  knee,  and  stiffness  and  awkwardness  in  movement  usually 
persist. 

In  many  of  the  milder  hemiplegic  cases  the  only  deformity  is 
of  the  foot.  This  should  be  treated  by  division  of  the  tendo- 
Achillis  and  by  support  for  a  time  until  the  deformity  habit  has 
disappeared. 

If  the  arm  is  but  slightly  affected  proper  exercises  will  greatly 
improve  its  ability.  In  the  more  extreme  cases,  in  which  the 
fingers  are  clasped  over  one  another,  treatment  is  of  little  avail. 
In  another  class,  in  which  the  patient  has  the  power  of  extend- 
ing the  fingers  only  when  the  wrist  is  flexed,  the  power  of  dorsi- 
flexion  may  be  restored  or  improved  by  transplanting  the  flexors 
of  the  carpus  on  the  radial  and  ulnar  border  to  the  extensors, 
which  have  been  overlapped  and  shortened  to  the  proper  extent. 
These  tendons  may  be  exposed  by  lateral  incisions,  and  may  be 
attached  to  the  dorsal  tendons  by  passing  them  about  the  border 
of  the  radius  and  of  the  ulna,  or  the  tendons  may  be  elongated 
by  silk,  which  may  be  inserted  directly  to  the  median  surface  of 
the  tarsus  or  metatarsus.  In  such  instances  one  hopes  that 
fibrous  tissue  will  be  deposited  about  the  artificial  tendon  and 
finally  replace  it.  In  other  instances  the  two  tendons  have  been 
pushed   tlu'ongli   an  opening  in  the  interosseous  membrane  to  the 


614 


ORTHOPEDIC  SURGERY. 


dorsal  surface  of  the  wrist,  and  there  united  with  the  tendons  of 
the  extensors  of  the  fingers.  The  results  of  these  operations  as 
far  as  improving  the  attitude  is  concerned  are  usually  good.  The 
transplantation  of  other  tendons  may  be  of  service,  but  the  opera- 
tion is  limited  in  usefulness  for  the  reasons  stated.^  Athetoid  move- 
ments of  the  hand  and  arm  may  be  relieved  somewhat  by  prolonged 
fixation  in  a  plaster  bandage,  or  by  arthrodesis  at  the  wrist-joint. 


Fig.  367. 


Cerebral  paraplegia,  second  stage  In  ireatment,  the  long  replaced  by  the  short  spica.  This 
patient,  at  the  age  of  eight  years,  was  unable  to  stand  without  assistance.  The  spastic  con- 
tractions and  deformities  were  overcome  by  tenotomies  and  by  force,  and  a  double  long  spica 
bandage  was  applied.  This  was  worn  for  eight  months.  It  was  then  replaced  by  the  ban- 
dage shown  in  the  illustration.  Six  months  later  this  was  removed.  There  is  at  present 
no  deformity,  and  the  child  walks  fairly  well. 

2.  Paraplegia.  The  treatment  of  spastic  paraplegia  is  much 
more  difficult  than  that  of  hemiplegia,  because  the  disability  is 
very  much  greater,  and  because  the  mental  impairment  is  usually 
more  marked. 


1  Townsend.    Transactions  American  Orthopedic  Association,  1900,  vol.  xiii. 


DISEASES  OF  THE  NEB  VO  US  S  YSTEM.  615 

In  general,  the  treatment  in  infancy  is  by  massage  and  by 
manipulation.  When  the  child  shows  a  desire  to  walk  an 
attempt  should  be  made  to  relieve  the  spastic  contractions.  In 
certain  instances  complete  correction  of  all  deformities,  followed 
by  prolonged  fixation  of  each  joint  in  the  overcorrected  attitude, 
may  be  of  service  (Fig.  367).  This  may  be  combined  with  mul- 
tiple tenotomies  if  the  contractions  are  more  resistant.  The 
advantage  of  tenotomy,  aside  from  the  simple  correction  of  de- 
formity, is  that  by  elongation  of  the  tendon  the  response  to  the 
exaggerated  motor  impulses  is  lessened  and  an  opportunity  for 
more  effective  control  is  afforded.  The  beneficial  effect  of  com- 
plete division  of  contracted  parts  in  checking  spasmodic  contrac- 
tions is  very  marked  in  older  patients.  Transplantation  of 
tendons  from  the  flexor  to  the  extensor  aspect  of  the  limb  to 
overcome  persistent  flexion  of  the  knee  may  be  of  service  in 
certain  cases.  According  to  the  method  of  Lange,  the  tendons 
are  exposed  by  incisions  on  the  lower  lateral  aspects  of  the  knee. 
They  are  then  carried  forward  beneath  the  skin  and  are  attached 
to  the  insertion  of  the  quadriceps  extensor  tendon,  which  is 
exposed  by  a  median  incision.  The  actual  insertion  is  usually 
made  by  a  strong  cord  of  silk  prolonged  from  the  extremity  of 
each  tendon.  This  is  necessary  to  give  it  sufficient  length. 
The  good  effect  of  the  operation  is  to  be  ascribed  in  all  proba- 
bility in  far  greater  degree  to  the  removal  of  the  deforming  force 
than  to  the  extending  action  of  the  flexor  muscles.  Except  in 
the  very  mild  cases  of  paraplegia,  and  as  an  aid  in  retaining  the 
limbs  in  the  improved  position  after  operative  treatment,  braces 
are  of  little  value.  The  trunk  is  not,  as  a  rule,  deformed 
except  in  the  diplegic  cases  in  which  the  mental  impairment  is 
great.  Manipulation,  massage,  and  posture  are  of  some  service 
in  correcting  and  preventing  this  distortion. 

Prognosis.  It  is  stated  by  Peterson^  that  the  patients  in 
whom  the  paralysis  is  paraplegic  or  diplegic  in  distribution 
usually  die  before  the  twentieth  year,  and  that  but  few  of  those 
in  whom  it  is  hemiplegic  reach  the  age  of  forty.  This  pi'og- 
nosis  applies,  it  may  be  assumed,  rather  to  the  extreme  cases 
accompanied  Ijy  mental  impairment  than  to  the  milder  forms. 
In  almost  all  cases  the  patient,  even  if  idiotic,  is  finally  able  to 
stand  and  to  walk.  As  a  rule,  there  is  for  a  time  a  gradual 
improvement  in  motor  power  and  in  mental  control  as  well.      It 

1  Transactions  American  Orthopedic  Association,  1900,  vol.  xiii. 


616  ORTHOPEDIC  S UE OEB  Y. 

is  evident  that  in  a  class  in  which  mental  enfeeblement  is  so 
common  and  in  which  epilepsy  is  present  in  so  large  a  propor- 
tion of  cases,  moral  and  mental  training  is  of  great  importance. 

Orthopedic  treatment,  although  it  has  no  direct  action  upon 
the  lesion  in  the  brain,  certainly  has  an  indirect  effect  upon  the 
mental  as  well  as  upon  the  physical  condition  of  the  patient. 
When  deformity  has  been  corrected  and  when  contractions  have 
been  overcome,  functional  use  requires  less  mental  efPort ;  and 
motor  control  may  be  still  further  improved  by  drilling  the  patient 
constantly  in  simple  movements.  Such  exercises  improve  the 
motor  communications  and  the  ability  of  the  paralyzed  part  as 
well. 

Spastic  Spinal  Paralysis. 

Occasionally  one  encounters  cases  of  spastic  paraplegia  in 
which  there  is  no  cerebral  impairment.  In  such  cases  the  lesion 
appears  to  be  confined  to  the  spinal  cord  and  to  be  a  degeneration 
of  the  distal  portions  of  the  pyramidal  tracts  due  to  imperfect 
development.^  The  treatment  is  similar  to  the  ordinary  form  of 
spastic  paraplegia,  but  the  prognosis  is  far  more  encouraging. 

Progressive  Muscular  Atrophy. 

Progressive  muscular  atrophy,  as  the  term  implies,  is  a  pro- 
gressive wasting  of  the  muscles,  with  corresponding  loss  of  power, 
terminating  finally  in  paralysis  and  deformity.  Its  cause  is 
apparently  some  developmental  defect. 

Under  this  title  are  included  two  varieties  of  disease : 

1.  The  myelopathic  form,  in  which  the  primary  disease  is  ap- 
parently of  the  spinal  cord. 

2.  The  myopathic  form,  in  which  the  disease  appears  to  be 
primarily  of  the  nerve  terminals  and  the  muscular  fibres. 

The  second  variety  is  usually  designated  as  muscular  dystrophy 
to  distinguish  it  from  the  spinal  form. 

Myelopathic  Paralysis  or  Atrophy.  The  myelopathic  form 
of  muscular  atrophy,  the  Aran-Duchenne  type,  usually  begins  in 
the  small  muscles  of  the  hands  and  spreads  from  the  periphery 
to  the  trunk.  Fibrillary  twitching  of  the  affected  and  unaffected 
muscles  is  fairly  constant,  and  the  reaction  of  degeneration  may 
be  present.  The  disease  is  practically  limited  to  adults,  and 
from  the  orthopedic  standpoint  it  is  of  little  interest.  In  another 
form,  the  Charcot-Marie-Tooth  type,  usually  classed  with    the 

'  Spiller.    Philadelphia  Medical  Journal,  June  21, 1902. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


617 


muscular  atrophies,  the  paralysis  may  begin  in  the  muscles  of  the 
legs,  causing  deformity  of  the  equinus  or  equinovarus  variety. 
The  lesion  of  the  cord  in  muscular  atrophy  is  of  the  anterior 
cornua,  and  resembles  closely  that  of  the  subacute  form  of 
anterior  poliomyelitis. 


F:g.  368. 


Fig.  369. 


Progressive  muscular  dystrophy, 
showing  the  enlargement  of  the  calves 
and  the  atrophy  of  the  shoulder  muscles. 


Progressive  muscular  dystrophy,  facio- 
scapulo-humeral  type.  Extreme  lordosis 
and  flexion  contractions  at  the  hips. 


Myopathic  Paralysis  or  Muscular  Dystrophy.  The  myo- 
pathic form  of  muscular  atroj)liy  may  be  preceded  by  apparent 
hypertrophy  (pseudohypertrophic  muscular  paralysis),  it  may  be 
primarily  atrophlr;,  or  tlu;  two  forms  may  be  combined. 


618  ORTHOPEDIC  SURGERY. 

It  differs  from  the  myelopathic  form  in  several  particulars. 
It  is  a  disease  of  childhood.  It  is  often  hereditary  and  its  dis- 
tribution is  different. 

The  affection  is  divided  according  to  the  distribution  into  two 
mam  varieties : 

1.  The  facio-scapulo-humeral  type  (Landouzy-Dejerine),  in 
which  the  muscles  of  the  face  and  shoulder  girdle  are  primarily 
affected  (Fig.  369). 

2.  The  juvenile  form  of  Erb,  in  which  the  muscles  of  the  back 
and  of  the  upper  arms  are  first  involved. 

The  etiology,  pathology,  and  clinical  course  of  the  atrophic 
do  not  differ  essentially  from  the  pseudohypertrophic  form. 

Pseudohypertrophic  Muscular  Paralysis.  Pseudohyper- 
trophic paralysis  is  characterized  by  progressive  weakness  of  the 
muscles  of  the  trunk  and  of  the  legs,  associated  with  apparent 
hypertrophy  of  the  calves  due  in  great  part  to  a  deposit  of  fat  in 
the  wasting  muscles  (Fig.  368). 

The  symptoms  are  caused  by  a  degenerative  atrophy  of  the 
nerve  terminals  and  of  the  muscular  fibres  and  an  increase  of  the 
connective  tissue  and  replacement  of  the  muscular  substance 
by  fat. 

Diagnosis.  The  interest  in  this  latter  affection  from  the  ortho- 
pedic standpoint  lies  in  the  diagnosis  in  the  early  stage  of  the 
affection.  At  this  time  the  patient  is  evidently  weak;  he  walks 
with  an  awkward,  shambling  gait,  and  climbing  stairs  is  especially 
difficult.  There  is  usually  an  increased  lordosis  and  a  peculiar 
swaying  or  waddle,  a  disinclination  to  stoop,  and  an  evident 
difficulty  in  regaining  the  erect  posture,  and  there  may  be  dis- 
comfort or  pain  referred  to  the  lumbar  region.  If  the  disease 
is  advanced,  the  peculiar  hard,  resistant  enlargement  of  the  calves, 
combined,  it  may  be,  with  atrophy  of  the  muscular  groups  of  the 
upper  extremity,  and  weakness  of  the  muscles  of  the  back,  makes 
the  diagnosis  evident,  but  in  young  children  the  disease  may  be 
mistaken  for  Potfs  disease,  simple  weakness,  or  j^ostural  deformity. 
Although  there  is  a  superficial  resemblance  to  the  general  symp- 
toms of  Pott's  disease,  yet  the  specific  signs  of  disease  of  the 
vertebrae,  pain,  and  muscular  spasm  are  absent. 

Weakness,  a  result  of  malnutrition  or  disease,  is  general  in 
character  and  its  cause  is  usually  apparent ;  it  is,  of  course,  not 
accompanied  by  local  hypertrophy.  Retarded  cerebral  develop- 
ment causes  general  weakness  as  far  as  inability  to  stand  is  con- 
cerned, but  the    cause  is   in  this    class  also    usually   apparent. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  619 

Postural  deformities  in  childhood  always  have  a  cause,  and  as  one 
is  not  content  to  treat  a  deformity  without  ascertaining  its  cause, 
this  search  will  bring  to  light  the  peculiar  symptoms  of  the  disease. 

Treatment.  In  certain  instances  the  discomfort  referred  to 
the  back,  due  in  part  to  the  lordosis,  may  be  relieved  by  a  light 
spinal  support.  Massage  and  muscle-training  may  enable  the 
patient  to  utilize  the  remaining  power  to  best  advantage. 

In  the  later  stages  of  the  disease  there  may  be  secondary 
deformities,  most  marked  in  the  feet,  which  may  be  fixed  in  the 
equinus  or  equinovarus  attitude.  This  deformity  may  be  cor- 
rected by  tenotomy  or  otherwise,  if  the  patient  has  not  already 
become  so  weak  that  walking  or  standing  is  impossible. 

Hereditary  Ataxia.     Friedreich's  Disease. 

Hereditary  ataxia  is  an  ataxic  paraplegia  caused  by  sclerosis  of 
the  posterior  and  lateral  columns  of  the  spinal  cord.  The  early 
symptoms  are  inco-ordination  and  weakness  of  the  legs  ;  later 
similar  symptoms  appear  in  the  upper  extremities  and  speech  is 
affected.  In  well-marked  cases  there  is  usually  distortion  of  the 
feet  toward  equinus  or  equinovarus,  and  occasionally  a  posterior 
or  lateral  curvature  of  the  spine.  In  one  case  recently  under 
treatment  at  the  Hospital  for  Ruptured  and  Crippled,  the  recti- 
fication of  the  deformity  of  the  feet  was  at  least  of  temporary 
benefit.    . 

Neuritis. 

Localized  neuritis  after  contagious  disease  or  from  other  causes 
may  result  in  temporary  weakness  or  paralysis  of  the  dorsal 
flexors  of  the  foot,  cause  toe-drop,  and,  finally,  deformity.  In 
such  cases  the  foot  should  be  supported  by  a  brace  in  normal 
position.  This  not  only  prevents  deformity,  but  it  hastens  the 
cure  by  preventing  tension  upon  and  structural  lengthening  of 
the  weakened  muscles.  The  same  treatment  may  be  applied  for 
wrist-drop  from  metallic  poisoning.  The  hand  should  be  sup- 
ported by  a  suitable  brace  in  the  attitude  of  dorsiflexion  until 
the  muscles  have  recovered  their  power.  Obstetrical  paralysis 
has  been  considered  under  affections  of  the  shoulder. 

Hysterical  Joint  Affections  and  Deformities.     Functional 
Affections  of  the  Joints. 

So-called  hysterical  and  functional  affections  may  be  divided 
into  two  groups  : 


620  ORTHOPEDIC  SURGERY. 

1.  Those  in  which  there  is  no  actual  disease  or  weakness. 

2.  Those  in  which  the  symptoms  of  disease  or  injury,  or  of 
their  effects,  are  exaggerated  or  prolonged. 

The  first  class  of  cases  is  small,  the  second  is  large. 

Simulation,  whether  voluntary  or  involuntary,  of  organic  dis- 
ease can  deceive  only  those  who  are  not  familiar  with  the  char- 
acteristics of  the  disability  that  is  simulated.  Every  disease  has 
certain  well-defined  symptoms  which  can  no  more  be  imitated  by 
a  well  person  than  a  disabled  part  can  suddenly  take  on  the 
normal  appearance  and  function. 

"Hysterical  Hip." 

The  hysterical  hip  is  supposed  to  simulate  actual  tuberculous 
disease. 

Diagnosis.  The  symptoms  of  actual  disease  of  this  joint  are 
pain,  limp,  limitation  of  motion  due  to  reflex  muscular  spasm, 
muscular  atrophy,  distortion,  and  in  the  later  stages  the  local 
signs  of  a  destructive  process  ;  for  example,  heat,  swelling,  abscess 
and  displacement  of  the  parts,  shortening  of  the  limb,  and  the 
like.  As  these  later  symptoms  could  not  be  simulated,  they  need 
not  be  considered. 

In  actual  disease  symptoms  and  effects  follow  one  another 
in  regular  sequence  and  correspond  closely  to  the  pathological 
conditions  that  cause  them.  Pain  is  not  a  pronounced  symptom  ; 
it  is  more  likely  to  be  concealed  than  exaggerated  and  it  is 
usually  referred  to  the  knee.  Local  sensitiveness  is  not  marked, 
and  it  is  often  absent.  Distortion  of  the  limb  when  it  occurs  in 
the  early  stage,  before  the  destructive  changes  are  advanced,  is 
caused  by  involuntary  muscular  contraction,  and  whenever  this 
distortion  is  great  the  reflex  muscular  spasm,  which  involves  every 
muscle  about  the  joint,  is  also  great ;  so  that  the  range  of  motion 
in  the  joint  is  small,  and  it  may  be  absolutely  restricted.  With 
the  distortion  there  is  always  a  corresponding  atrophy  of  the 
muscles  of  the  limb.  If  pain  is  present  it  is  usually  worse  at 
night  than  during  the  day. 

The  hysterical  simulation  of  hip  disease  is  characterized  by  an 
exaggeration  of  the  symptoms  and  by  absence  of  the  physical 
signs  of  disease.  There  is  usually  an  exaggerated  limp,  great 
distortion,  marked  local  sensitiveness  and  pain,  but  absence  of 
muscular  spasm,  atrophy,  or  other  signs  of  disease. 

The  age  of  the  patient,  the  history  of  the  supposed  disease,  and 


DISEASES  OF  THE  NERVOUS  SYSTEM.  621 

the  other  evidences  of  hysteria  that  are  usually  present  will  con- 
firm the  diagnosis. 

The  same  principle  applies,  of  course,  to  the  differential  diag- 
nosis of  simulated  disease  at  other  joints.  The  knee  and  the  hip 
are  those  that  are  most  often  involved. 

Hysterical  Deformities. 

"Hysterical  Club-foot."  Local  deformity  distinct  from  simu- 
lated joint  disease  is  sometimes  seen.  Several  cases  of  this 
character  in  which  the  foot  was  distorted  have  been  under  treat- 
ment at  the  Hospital  for  Ruptured  and  Crippled  recently.  The 
differential  diagnosis  is  simple. 

Talipes  is  either  congenital  or  acquired.  Congenital  talipes 
and  all  the  acquired  varieties,  other  than  those  of  paralytic  origin, 
may  be  at  once  excluded  from  consideration.  Paralytic  talipes 
in  the  vast  majority  of  cases  begins  in  early  childhood,  when  it  is 
either  caused  by  anterior  poliomyelitis  or  of  cerebral  hemiplegia 
or  paraplegia.  When  these  are  excluded  the  remaining  causes 
of  deformity  are  very  limited.  Every  variety  of  nervous  disease 
has  well-defined  symptoms.  If  actual  paralysis  is  present  the 
muscles  atrophy  and  the  electrical  reactions  are  changed.  In 
hysterical  contractions  the  muscles  do  not  atrophy,  and  the  elec- 
trical reactions  are  unchanged. 

"  Hysterical  Scoliosis."  A  case  was  recently  under  observa- 
tion at  the  Hospital  for  Ruptured  and  Crippled  in  which  distortion 
of  the  trunk  persisted  for  more  than  a  year,  and  until  a  suit  for 
damages  was  finally  decided.  In  this  case  there  was  a  most 
exaggerated  lateral  twist  of  the  spine,  so  that  the  shoulder 
approached  the  pelvis.  The  deformity,  however,  was  not  fixed, 
but  it  could  be  comjaletely  reduced  when  the  patient  was  in  the 
recumbent  posture.  There  was  no  paralysis,  no  persistent  spasm, 
no  evidence  of  disease  or  injury.  The  deformity  was  of  a  nature 
that  could  not  be  explained  by  any  conceivable  lesion,  and  other 
signs  of  hysteria  were  present. 

Treatment.  The  principles  of  the  treatment  of  pronounced 
hysteria,  of  which  simulated  joint  disease  or  deformity  are  but 
unusual  manifestations,  are  considered  at  length  in  medical  and 
neurological  works,  and  the  subject  does  not  call  for  special 
mention  here.  It  is  evident,  of  course,  that  an  unequivocal 
diagnosis  must  ]>(•  tlie  first  and  essential  step  toward  cure.  In 
this  class  of  cases  apparatus  is  not  often  indicated  unless  the 


622  ORTHOPEDIC  S UB OER  Y. 

deformity  has  persisted  for  so  long  a  time  that  the  disused 
muscles  have  become  incapable  of  performing  their  proper 
functions. 

Functional  Affections  of  the  Joints. 

"  Neurotic  Joints."  In  this  class,  although  there  is  no  abso- 
lute distinction  between  it  and  the  preceding  variety,  there  is 
usually  a  physical  basis  for  the  symptoms,  however  much  they 
may  be  exaggerated. 

The  patients  are  not  usually  hysterical ;  in  fact,  hysteria  in 
the  ordinarily  accepted  sense  is  uncommon,  and  although  the 
larger  proportion  of  patients  are  women,  yet  men  and  children 
are  by  no  means  exempt  from  the  so-called  functional  affections. 

It  must  be  borne  in  mind,  also,  that  many  of  these  cases  are 
classed  as  neurotic  simply  because  the  cause  of  the  symptoms  is 
not  apparent.  It  is  only  within  a  few  years  that  the  slighter 
degrees  of  weak  foot  and  its  effects  have  been  recognized,  and  it 
is  probable  that  such  cases,  together  with  anterior  metatarsalgia, 
the  painful  fascia  of  the  contracted  foot,  achillodynia,  and  the 
like  might  be  considered  as  neurotic  by  one  unfamiliar  with  their 
symptoms.  It  may  be  inferred  that  as  diagnosis  becomes  more 
accurate  the  more  restricted  will  become  the  class  of  cases  of 
purely  imaginary  disability,  in  so  far  at  least  as  the  locomotive 
apparatus  is  concerned. 

A  "  neurotic  joint "  is  often  caused  by  injury.  A  sprain  of 
the  ankle,  for  example,  may  have  been  treated  by  prolonged 
immobilization,  either  because  the  patient  had  originally  impressed 
the  physician  with  the  severity  of  the  symptoms  or  because  of 
persistent  discomfort.  When  the  dressing  is  removed  there  may 
be  congestion  and  discoloration  due  to  impaired  circulation,  weak- 
ness and  atrophy  of  the  muscles  due  simply  to  disuse,  and  a 
certain  degree  of  infiltration  and  stiffness  caused  by  the  original 
injury.  In  cases  of  this  character  the  disability  may  be  pro- 
longed because  the  patient  or  the  physician  mistakes  the  effects 
of  disuse  for  the  symptoms  of  serious  injury  or  disease.  When 
the  diagnosis  has  been  made  treatment  should  be  directed  to 
increasing  the  activity  of  the  circulation  and  thus  the  nutrition 
of  the  part,  by  counter-irritation,  by  massage,  by  passive  move- 
ments, by  voluntary  exercises  and  the  like,  but  cure  can  only  be 
completed  by  restoring  functional  use.  If,  therefore,  the  disa- 
bility is  of  long  standing  a  temporary  brace  will  be  required 
to    protect  the    part  from  injury,  and  to  increase  the   patient's 


DISEASES  OF  THE  NERVOUS  SYSTEM.  623 

confidence.  In  milder  cases  it  is  possible  that  without  sup- 
port or  treatment,  other  than  an  assurance  of  the  absence  of 
serious  weakness,  cure  may  be  accomplished,  but  this  is  certainly 
unusual. 

What  has  been  said  of  exaggerated  disability  at  the  ankle  fol- 
lowing traumatism  applies  to  the  treatment  of  similar  affections 
elsewhere.  The  knee-joint  is  very  often  the  seat  of  so-called 
neurosis.  Injury  at  this  point  in  nervous  children  is  often  fol- 
lowed by  a  persistent  flexion  contraction  that  may  continue  for 
weeks  after  all  signs  of  the  injury  have  disappeared.  When  the 
attempt  is  made  to  straighten  the  knee  the  patient  screams  with 
pain  and  the  muscular  resistance  is  very  great.  In  such  cases 
the  immediate  rectification  of  deformity  and  the  application  of  a 
plaster  bandage  to  hold  the  limb  in  the  corrected  position  is 
indicated.  It  must  be  borne  in  mind  that  the  persistent  assump- 
tion of  a  deformed  position  for  weeks  or  months  must  be  followed 
by  certain  structural  changes  in  the  contracted  muscles  and  weak- 
ness in  the  opposing  groups.  Thus  some  assistance  may  be 
required  in  the  treatment  even  of  the  purely  hysterical  deformities 
because  of  this  weakness. 

In  all  forms  of  traumatic  neurosis,  so  called,  the  possibility  of 
a  physical  basis  for  the  symptoms  should  be  considered,  the 
location  of  the  pain  or  discomfort,  and  its  connection  with  cer- 
tain movements  or  attitudes  should  be  investigated.  If  such 
discomfort  is  induced  or  is  aggravated  always  by  a  certain  motion 
or  attitude  it  is  reasonable  to  infer  that  this  has  a  well-defined 
cause,  especially  as  the  pain  of  a  neurotic  affection  is  not  often  of 
this  definite  character.  In  this  class  of  cases  limitation  of  move- 
ment for  a  time  to  the  painless  range  of  motion  by  some  form  of 
support  may  be  indicated. 

Thus  far  injury  has  been  considered  as  the  starting  point  of 
the  symptoms,  but  in  many  cases  there  is  no  history  of  injury. 
In  this  class  the  symptoms  may  have  been  induced  by  rheu- 
matism or  gout  or  rheumatoid  arthritis,  or  by  neuritis,  and  such 
possible  causes  should  be  investigated  and  excluded  before  the 
diagnosis  of  simple  neurosis  is  made.  In  neurasthenic  patients 
or  those  who  are  anaemic,  or  overworked,  the  pain  and  discomfort 
is  often  localized  in  the  spine.  The  "  neurotic  spine  "  has  been 
considered  elsewhere.  In  the  treatment  of  all  cases  of  this 
group  the  general  condition  of  the  patient  should  receive  con- 
sideration, and  in  connection  with  the  local  treatment  a  change 
of  occupation  and  of  scene  is  often  of  advantage. 


624  OR THOPEDIC  S UR  GER  Y. 

It  is  hardly  necessary  to  insist  again  that  an  accurate  diagnosis 
is  the  first  essential  of  successful  treatment.  If  this  is  impossible 
at  least  one  may  by  exclusion  of  those  injuries  and  disabilities 
and  diseases  which  are  evidently  not  present  arrive  at  a  general 
conclusion  as  to  the  character  of  the  ailment  and  shape  his  treat- 
ment accordingly. 


CHAPTEK   XIX. 

CONGENITAL  AND  ACQUIRED  TORTICOLLIS. 

Synonym.     Wryneck. 

Torticollis  is,  as  the  name  implies,  a  twisted  neck,  a  distortion 
caused  in  most  instances  by  active  contraction  or  by  shortening 
of  one  or  more  of  the  lateral  muscles  that  control  the  head. 
Similar  distortion  may  be  due  to  disease  of  the  spine,  so-called 
false  torticollis,  but  this  should  be  classed  as  a  symptom  of  the 
underlying  disease,  not  as  simple  torticollis,  of  which  the  distor- 
tion itself  is  the  important  disability  that  demands  treatment. 

Torticollis  may  be  divided  primarily  into  two  classes  :  the 
congenital  and  the  acquired. 

Congenital  torticollis  is  a  painless  shortening  of  the  tissues  on 
one  side  of  the  neck  of  intra-uterine  origin. 

Acquired  torticollis  is,  in  most  instances,  accompanied  in  its 
early  stages  by  local  pain  and  sensitiveness,  and  by  active  con- 
traction of  the  affected  muscles.  After  a  time  these  acute 
symptoms  disappear,  leaving  simply  the  deformity.  Thus,  from 
the  therapeutic  standpoint,  torticollis  may  be  classified  as  acute 
and  chronic,  the  latter  class  including  the  congenital  form. 

The  sternomastoid  is  the  muscle  that  is  usually  involved 
primarily,  both  in  the  congenital  and  acquired  forms  ;  thus,  in 
typical  torticollis  the  head  is  drawn  somewhat  forward  and  is 
inclined  toward  the  contracted  muscle,  while  the  neck  is  pushed, 
as  it  were,  away  from  the  contraction  (Fig.  370)  ;  the  chin  is 
slightly  elevated,  and  turned  toward  the  opposite  shoulder — an 
attitude  explained  by  the  normal  action  of  the  affected  muscle. 
Irregular  distortions  of  the  head,  as  posterior  or  anterior  torti- 
collis due  to  contraction  of  muscles  other  than  the  sternomastoid, 
are,  however,  not  infrequent.  These  will  be  mentioned  in  the 
consideration  of  the  forms  of  acquired  torticollis. 

Statistics.  Torticollis  is  comparatively  an  uncommon  defor- 
mity. In  a  period  of  twenty-seven  years  507  cases  were  treated 
at  the  Hospital  for  JIuptured  and  Crippled,  as  contrasted  with 
upward  of  5000  cases  of  congenital  and  acquired  talipes. 

Acquired  torticollis   is  by  far  the  more  common  variety,  as  is 

40 


626 


OR  THOPEDIC  S  UB  GEB  Y. 


shown  by  the  fact  that  of  the  507  cases  but  87  were  supposed  to 
be  of  congenital  origin. 

It  is  often  stated  that  torticollis  is  more  common  in  males 
than  in  females,  and  that  the  right  side  is  more  often  affected, 
yet  46  of  the  87  congenital  cases  were  in  females  and  the  contrac- 
tion was  of  the  left  side  in  38  of  the  58  cases  in  which  the  affected 
side  was  specified.  Of  the  entire  number  of  cases  available  for 
comparison  246  were  in  females  and  198  in  males ;  in  236 
instances  the  contraction  was  on  the  left  and  iu  196  on  the  right 
side  of  the  neck.  From  these  statistics  it  would  appear  that  the 
deformity  is  somewhat  more  common  in  females  than  in  males, 
and  that  the  left  side  is  more  often  affected  than  the  right. 

Congenital  Torticollis. 

In  most  instances  the  deformity  of  congenital  torticollis  is 
slight  at  birth,  and  it  may  not  attract  attention  until  the  child 
sits  or  walks.     Thus  it  is  often  difficult  to  distinguish  the  con- 


FlG.  370. 


Left  torticollis,  apparently  of  congenital  origin,  showing  the  secondary  distortions 
of  head  and  face. 

genital  form  from  the  deformity  that  may  have  been  acquired 
in  infancy,  especially  as  the  patient  may  not  be  brought  for  treat- 
ment until  the  distortion  has  persisted  for  many  years. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS. 


627 


In  early  infancy  slight  torticollis  may  be  demonstrated  by 
fixing  the  shoulder  on  the  affected  side  and  drawing  the  head 
forcibly  in  the  opposite  direction,  when  the  shortened  muscle 
becomes  prominent  beneath  the  skin,  evidently  restricting  the 
range  of  motion.  In  most  instances  the  sternal  division  of  the 
muscle  appears  to  be  more  shortened  than  the  clavicular  portion. 

In  exceptional  cases  the  deformity  even  in  infancy  may  be 
extreme,  and  it  may  be  accompanied  by  well-marked  asymmetry 
of  the  face  and  even  by  distortion  of  the  skull.     In  this  class 


Fig.  371. 


Right  torticollis,  showing  the  displacement  of  the  head  toward  the  opposite  side. 


the  shortening  may  involve  all  the  lateral  tissues,  both  anterior 
and  posterior.  Slight  asymmetry  may  be  present  at  birth 
and  becomes  more  marked  with  the  growth.  Even  in  the 
acquired  form  it  appears  usually  soon  after  the  onset  of  the  de- 
formity, becoming  more  marked  with  its  continuance.  Its  cause 
is  the  constrained  attitude,  the  restriction  of  normal  use,  and 
consequently  of  the  blood  supply,  combined  with  the  tension 
upon  the  tissues  of  the  face,  as  is  evidenced  by  the  fact  that  it 
becomes  less  noticeable  after  the  deformity  has  been  corrected. 


628  ORTHOPEDIC  SUBGEBY. 

In  the  well-marked  cases  of  long  standing,  whether  congenital 
or  acquired,  the  face  is  shorter  and  flatter,  the  nose  and  the  corner 
of  the  mouth  and  the  eyelids  even  on  the  affected  side  are  drawn 
downward,  and  the  skull  shows  evidence  of  atrophy  and  de- 
formity. 

Secondary  distortions  also  appear  in  the  trunk  in  chronic  cases. 
These  are  rotation  of  the  spine  to  compensate  for  the  lateral  dis- 
tortion of  the  head  and  an  increase  in  the  dorsal  kyphosis,  "  round 
shoulders."  Among  the  minor  secondary  deformities  upward 
bowing  of  the  clavicle  caused  by  the  tension  of  the  contracted 
muscle  may  be  mentioned  (Fig.  370). 

In  the  early  stage  of  torticollis  the  head  is  tilted  toward  the 
contracted  tissues,  but  when  the  deformity  is  of  longer  standing 
the  head  following  the  compensatory  convexity  of  the  cervical 
spine  appeajrs  to  be  displaced  toward  the  opposite  shoulder  and 
the  inclinatipn  may  be  less  marked  (Fig.  371). 

The  compensatory  deformities  that  have  been  indicated  are 
slight  in  infancy,  but  they  become  more  marked  in  later  child- 
hood, for  in  many  instances  the  shortened  muscle  ceases  to  grow  ; 
thus,  an  original  shortening  of  half  an  inch,  as  compared  to  its 
fellow,  may  \  be  increased  to  two  or  more  inches  in  later  years. 
This  fact  emphasizes  the  importance  of  treatment  as  soon  as  may 
be  possible  after  the  distortion  is  discovered. 

As  has  been  stated,  the  important  contraction  is  usually  of  the 
sternomastoid  muscle,  but  if  the  deformity  is  uncorrected  all  the 
lateral  tissues  become  shortened,  so  that  at  a  later  stage  complete 
division  of  the  cervical  fascia  as  well  as  of  the  muscles  may  be 
necessary  before  the  deformity  can  be  corrected. 

Typical  wryneck  caused  by  shortening  of  the  sternomastoid 
muscle  is  by  far  the  most  common  form  of  congenital  torticollis, 
but  occasionally  cases  are  seen  in  which  the  head  is  but  slightly 
inclined  to  one  side  and  in  which  the  shortening  appears  to 
involve  the  lateral  tissues  in  general  rather  than  a  particular 
muscle.  In  rare  instances,  although  the  deformity  resembles 
that  of  typical  torticollis,  the  greatest  shortening  will  be  found  to 
be  of  the  posterior  muscles  on  one  side,  particularly  of  the 
trapezius  and  the  levator  auguli  scapulae.  Thus  the  scapular 
may  be  elevated  and  tilted  forward.  This  form  of  torticollis 
appears  to  be  one  variety  of  congenital  elevation  of  the  scapula. 
(See  page  229.)  Torticollis  due  to  defective  development  of  the 
upper  extremity  of  the  spine  is  a  rare  deformity  that  does  not 
require  special  description. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  629 

Etiology.  It  may  be  assumed,  disregarding  the  possible 
influence  of  hereditary  predisposition,  that  congenital  torticollis 
is,  in  most  instances,  caused  by  a  constrained  or  fixed  position 
in  the  uterus  for  a  longer  or  shorter  time  before  birth.  It  is,  in 
fact,  a  simple  distortion  ;  and  that  it  has,  in  the  majority  of 
cases,  no  deeper  significance  is  proved  by  the  fact  that  it  may  be 
easily  and  completely  cured  by  simple  division  or  elongation  of 
the  contracted  tissues. 

It  would  seem  that  a  deformity  to  be  properly  congenital  must 
be  present  at  birth,  yet  the  theory,  first  advanced  by  Stromeyer, 
that  congenital  torticollis  is  usually  the  result  of  injury  at  birth, 
has  been  so  generally  accepted  that  it  merits  further  consideration. 

Hsematoma  of  the  Sternomastoid  Muscle.  Hsematoma  is  con- 
sidered to  be,  and  undoubtedly  is,  evidence  of  injury.  During 
difficult  delivery  fibres  of  the  muscle  are  ruptured,  usually  in 
the  upper  or  middle  third  of  the  anterior  border,  hemorrhage 
follows,  which  in  turn  is  surrounded  by  an  encapsulating  area  of 
inflammatory  material.  This  forms  a  firm,  cylindrical  tumor  in 
the  substance  of  the  muscle,  which  becomes  noticeable  about  two 
weeks  after  birth,  or  at  least  this  is  the  time  when  it  is  usually 
discovered  by  the  mother.  As  a  rule,  the  tumor  is  not  sensitive 
to  pressure  ;  it  may  or  may  not  be  accompanied  by  restriction  of 
motion  in  the  direction  causing  tension  on  the  muscle.  The 
tumor  remains  for  from  three  to  six  months,  when  it  usually 
disappears,  leaving  no  trace  of  its  presence. 

The  theory  of  Stromeyer,  which  until  recently  was  generally 
accepted,  is  that  congenital  torticollis  is  usually  caused  by  rupture 
of  the  muscle  and  by  myositis  about  the  hsematoma.  This  inflam- 
mation may  involve  and  ultimately  destroy  a  large  part  of  the 
substance  of  the  muscle,  replacing  it  with  fibrous  tissue,  which, 
contracting,  causes  deformity. 

This  theory  is  extremely  improbable  for  the  following  reasons : 

1.  Rupture  of  muscle  elsewhere  is  practically  never  followed 
by  myositis  and  contraction. 

2.  It  has  been  demonstrated  by  Heller'  that  it  is  impossible 
to  cause  myositis  and  contraction  by  any  form  of  injury  to  the 
muscles  of  animals  unless  it  be  combined  with  actual  infection 
with  pyogenic  germs. 

3.  Most  of  the  cases  of  congenital  torticollis  seen  soon  after 
birth  present  no  evidence  of  h«;matoma  or  injury,  viz.  :  In  7  of 

>  Heller.    Deutsche  Zelts.  f.  Chir.,  Bd.  xlix.  H.  2  and  3,  S.  234. 


630  ORTHOPEDIC  SUBQEBY. 

55  cases  of  supposed  congenital  torticollis,  investigated  by  the 
writer,  there  was  a  history  of  injury  at  birth.  In  48  cases  no 
mention  was  made  of  injury.  In  the  7  cases  referred  to  the 
deformity  was  accompanied  by  hsematoma  or  there  was  a  history 
of  a  swelling,  apparently  of  this  nature  ;  but  in  2  of  these  the 
haematoma  was  coincident  with  intra-uterine  shortening  of  the 
muscle. 

4.  Cases  of  hsematoma  of  the  sternomastoid  muscle  are  not,  as 
a  rule,  followed  by  torticollis.  Seven  consecutive  cases  of 
hsematoma  were  examined  by  the  writer  with  special  reference 
to  this  point.  In  all  the  evidence  of  violence  in  delivery  was 
clear.  Two  were  delivered  by  forceps,  3  were  breech  presenta- 
tions, and  in  2  version  was  performed.  In  1  case  an  arm  was 
broken  and  in  another  paralysis  resulted  from  injury  to  the 
brachial  plexus.  Six  of  the  children  lived  until  the  swelling  had 
nearly  or  entirely  disappeared,  and  in  none  did  torticollis  accom- 
pany or  follow  the  hsematoma. 

5.  In  certain  cases  a  congenitally  shortened  muscle  may  be 
ruptured  at  delivery ;  thus  the  hsematoma  is  simply  a  complica- 
tion of  torticollis,  not  its  cause.  Bruns^  has  reported  such  a 
case,  and  two  others  have  been  observed  by  the  writer,  in  one  of 
which  club-foot  was  present  also. 

6.  Hard  tumors  of  the  sternomastoid  muscle  are  not  always 
the  result  of  injury  ;  myositis  may  be  of  syphilitic  origin  appar- 
ently occurring  in  intra-uterine  life.  In  other  instances  tumors 
of  fibrous  or  sarcomatous  nature  have  been  removed  from  the 
substance  of  the  muscle.  Sixteen  cases  in  which  cartilaginous 
nodules,  apparently  of  congenital  origin,  were  found  in  the 
muscle  have  been  reported.^ 

Congenital  torticollis  in  the  majority  of  cases  is  of  intra-uterine 
origin.  If  it  follows  injury  at  birth  it  is  probably  an  indirect 
result  of  local  pain,  discomfort,  and  irritation  of  the  nerves  or  of 
an  actual  infectious  inflammation  of  the  injured  part  rather  than 
an  effect  of  the  absorption  of  effused  blood. 

Pathology.  In  the  ordinary  type  of  congenital  torticollis,  as 
demonstrated  at  operations  on  children,  the  substance  of  the 
affected  muscle  or  muscles  is  simply  lessened  in  amount,  and 
there  is  a  disproportionate  area  of  tendinous  substance  as  compared 
to  the  contractile  tissue.  In  other  instances  the  muscle  may  be 
almost  entirely  replaced  by  fibrous  tissue,  or  it  may  be  traversed 

1  Cent.  f.  Chir.,  1891,  No.  26.  =  Leugemann  Beitr.  z.  klin.  Chir.,  Bd.  xxx.  H.  1. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  631 

by  fibrous  bands,  or  patches  of  scar-like  tissue  may  be  distributed 
throughout  its  substance.  These  degenerative  changes,  consid- 
ered to  be  evidences  of  pre-existing  myositis,  are  probably  more 
common  among  the  acquired  than  the  congenital  form,  and,  as  a 
rule,  they  are  found  only  in  cases  of  long  standing.  Secondarily 
all  the  lateral  tissues  of  the  neck  are  shortened  to  correspond  to 
the  habitual  attitude,  and  the  compensatory  curvatures  of  the 
spine  in  time  become  fixed,  so  that  torticollis  may  be  classed  as 
one  of  the  causes  of  scoliosis. 

Acquired  Torticollis. 

Acquired  torticollis  is  an  affection  of  early  life,  at  least  80  per 
cent,  of  the  cases  beginning  in  the  first  ten  years  of  life. 

As  has  been  stated,  congenital  torticollis  is  usually  a  painless 
shortening  of  the  muscles,  while  acquired  torticollis  is,  as  a  rule, 
a  painful  affection  secondary  to  injury  or  disease  of  some  of  the 
structures  of  the  neck,  which  causes  peripheral  irritation  of  the 
nerves  and  active  contraction  of  the  neighboring  muscles.  Thus, 
as  a  rule,  the  number  of  muscles  involved  in  the  deformity  is 
greater  than  in  the  congenital  form ;  for  example,  in  the  ordinary 
form  of  acquired  wryneck  the  trapezius,  which  receives  in  part 
the  same  nerve  supply,  is  usually  involved  together  with  the 
sternomastoid ;  and  irregular  forms  of  distortion  caused  by  con- 
traction of  other  groups  are  not  uncommon. 

Varieties.  The  varieties  of  acquired  torticollis  may  be  clas- 
sified conveniently  as  follows  : 

1.  The  simple  or  mechanical  form  due  to  scar  contraction  fol- 
lowing destruction  of  the  skin  or  deeper  tissues,  as  from  burns 
or  disease. 

2.  Acute  torticollis  caused  by  direct  irritation  of  the  muscle,  by 
injury,  by  inflammatory  affections  of  the  surrounding  parts, 
combined  in  most  instances  with  irritation  of  the  peripheral 
nerves,  which  causes  reflex  contraction  of  certain  muscles  or 
muscular  groups. 

3.  Spasmodic  Torticollis.  A  form  of  convulsive  spasm,  "  a 
disorder  of  the  cortical  centres  for  rotation  of  the  head.^' 
(Walton.) 

4.  Irref/ular  Forms  of  Torticollis.  Paralytic,  ocular,  psychical, 
and  the  like. 

The  first  class,  that  duo  to  scar  contraction,  needs  only  to  be 
mentioned. 


632 


ORTHOPEDIC  SURGERY. 


Fig.  372. 


Etiolog-y  of  Acute  Torticollis.  The  second  class  is  the  most 
important  form  of  torticollis,  both  as  to  frequency  and  as  to  its 
effect  in  causing  permanent  distortion.  Of  this  group,  one  of  the 
most  common,  and  at  the  same  time  the  least  important  form,  is 
the  simple  stiff  neck,  supposed  to  be  due  to  cold  or  to  muscular 
rheumatism.  Its  onset  is,  in  childhood,  sometimes  accompanied 
by  slight  fever  and  malaise  ;  the  affected  muscle  is  somewhat 
sensitive  to  pressure  and  motion  or  tension  causes  discomfort. 
The  distortion,  in  great  part  voluntary  and  accommodative,  is  of 
short  duration  as  a  rule.  Strains  and  direct  injury  of  the  muscles 
of  the  neck  may  cause  deformity,  which  usually  disappears  when 

the  local  sensitiveness  has  sub- 
sided. Traumatic  hsematomata^ 
similar  to  those  caused  by  in- 
jury at  birth,  are  sometimes  ob- 
served in  older  subjects.  These 
usually  disappear  after  a  time, 
leaving  no  trace  of  their  pres- 
ence. 

Another  form  of  torticollis  is 
secondary  to  cellulitis  and  to  in- 
filtration following  the  breaking 
down  of  tuberculous  cervical 
glands.  This  may  become  a 
permanent  distortion  if  the  de- 
formity is  allowed  to  persist  or 
if  the  tissues  of  the  neck  are 
injured  by  the  suppurative 
process. 

By  far  the  most  important 
variety  of  this  class  is  the  acute 
spastic  torticollis  due  to  active 
tonic  contraction  of  one  or  more 
of  the  muscles  of  the  neck.  The  exciting  cause  of  the  spasm 
appears  to  be  irritation  of  the  peripheral  nerves  in  the  naso- 
pharynx or  in  its  neighborhood,  and  the  muscles  most  often 
affected  are  those  supplied  in  part  by  the  spinal  accessory  nerve. 
Thus  torticollis  of  this  form  may  follow  tonsillitis,  pharyngitis, 
measles,  diphtheria,  and  the  like.  It  may  be  preceded  by 
''  toothache  "  or  ''  earache,"  or  it  may  be  an  accompaniment  of 
what  appears  to  be  the  ordinary  form  of  stiff  neck,  or  of  enlarged 
or  suppurating  cervical  glands.     In  this  form  the  torticollis  is 


Bilateral  coutraction  of  the  sternomastoid 
and  trapezii  muscles.    (See  Fig.  373.) 


CONGENITAL  AND  ACQUIRED   TORTICOLLIS.  633 

caused  directly  by  tonic  contraction  of  the  muscles.  Reflex  spasm 
of  this  character  is,  however,  often  associated  with  the  distortion, 
due  primarily  to  injury  of  the  neck  or  to  some  local  inflammatory 
process,  so  that  a  sharp  distinction  between  the  divisions  of  this 
second  class  is  impossible.  Many  of  the  patients  are  known  to 
be  of  a  nervous  temperament,  and  overstudy,  anxiety,  sudden 
shock,  and  the  like  are  considered  to  be  predisposing  causes. 

This  variety  of  acquired  torticollis  completely  overshadows  in 
importance  all  other  forms,  as  is  indicated  by  the  statistics  of  212 
cases  treated  at  the  Hospital  for  Euptured  and  Crippled  in  which 
the  cause  seemed  to  be  apparent.  Of  the  212  cases  181  may  be 
fairly  assigned  to  this  class. 

The  apparent  exciting  causes  of  cases  of  acquired  torticollis 
treated  at  the  Hospital  for  Ruptured  and  Crippled  are  shown  in 
the  following  table  : 

Enlarged  cervical  glaods         .        .    14       Cold  in  the  neck 5 

Suppurating    "         "  .       .    41       Rheumatism 18 


Scarlet  fever 14       Vaccinia 1 

Diphtheria 7        Fever 6 

Mumps 6        Malaria 5 

Measles 2       Injury  to  the  neck 35 

Sore-throat 8        Rhachitis 3 

Suppurating  otitis     ....  3       Syphilis 1 

Toothache 6  Cicatricial  contraction   ....      3 

Cellulitis  of  the  neck        ...  2  — 

Furuncle      "         "           ...  1              Total 181 

Torticollis  associated  with  chorea 4 

"  "  "    epilepsy 1 

"  "  "    cortical  irritation 5 

"  "  "    hysteria 1 

"  "  "    meningitis 1 

"  "  "    hemiplegia 3 

Spasmodic  torticollis 8 

"  Functional  torticollis  " 8 

Total 31 

Symptoms  of  Acute  Torticollis.  As  a  rule,  the  distortion  of 
the  neck,  slight  at  first,  is  more  noticeable  at  night  than  in  the 
morning  ;  it  then  gradually  increases  until  the  deformity  becomes 
fixed.  In  other  instances  the  onset  is  sudden,  sometimes  accom- 
panied by  fever. 

As  has  been  stated,  in  most  instances  several  muscles  are  more 
or  less  involved  in  the  contraction,  particularly  the  sternomastoid 
and  the  trapezius,  and  in  such  cases  the  deformity  is  more  marked 
and  persistent  than  wlien  the  sternomastoid  is  alone  affected. 
Less  often  the  contraction  is  of  the  posterior  group,  "  posterior 
torticollis,"  when  the  head  is  tilted  backward  and  the  chin  is 
turned  more  toward  the  opposite  side  than  in  the  typical  lateral 
form.     In  other  cases  the  contraction  appears  to  affect  the  small 


634 


ORTHOPEDIC  SURGERY. 


muscles  that  control  the  small  joints  at  the  upper  extremity  of  the 
spine,  when  the  head  may  be  tilted  forward  with  but  slight  lateral 
inclination,  resembling  closely,  except  in  the  history,  the  symp- 
tomatic wryneck  of  Pott's  disease.  In  rare  instances  the  muscles 
on  both  sides  of  the  neck  may  be  contracted  simultaneously 
(Fig.  372).  The  contracted  muscles  are  usually  sensitive  to 
manipulation  and  attempted  rectification  of  the  deformity  causes 
extreme  pain  and  is  resisted  by  the  patient.  The  child  is,  as  a 
rule,  nervous  and  irritable ;  it  often  complains  of  neuralgic  pain 
about  the  contracted  part  which  is  increased  by  sudden  or 
unguarded  movements  or  strain;  thus   '^getting  the  patient  to 


Fig.  373. 


Bilateral  torticollis  after  treatment.    (See  Fig.  372.) 


bed "  is  often  a  tedious  proceeding,  because  of  the  difficulty  of 
supporting  the  head  comfortably  with  the  pillows. 

In  many  instances  the  affection  is  of  short  duration  ;  in  others, 
particularly  those  in  which  the  reflex  spasm  is  aggravated  by 
local  inflammatory  processes,  there  appears  to  be  but  little 
tendency  toward  recovery.  In  such  cases,  after  several  weeks 
or  months,  the  local  pain  and  sensitiveness  may  subside,  together 
with  the  active  spasm,  but  the  deformity  remains,  caused  by 
adaptive  shortening  of  the  muscles  and  fascia,  aggravated  in  some 
instances  by  actual  myositis.  The  muscles  atrophy  and  degen- 
erate and  present  at  a  later  stage  the  same  pathological  appear- 
ances that  are  found  in  the  congenital  form. 


CONGENITAL  AND  AGQUIBED  TORTICOLLIS.  635 

Diagnosis.  Torticollis  is  most  often  confounded  with  Pott's 
disease.  This  would  seem  to  be  hardly  possible  in  cases  of  the 
simple  painless  contraction  of  chronic  torticollis.  In  the  acute 
form,  however,  there  may  be  more  difficulty  in  distinguishing 
between  the  two.  The  main  points  have  been  mentioned  already 
in  connection  with  Pott's  disease.  In  acute  torticollis  the  affec- 
tion is  of  sudden  onset,  not  preceded  by  the  stiffness  and  neuralgic 
pain  that  characterize  tuberculous  disease.  The  deformity  of 
torticollis  is  almost  always  of  the  regular  type — that  is,  the  head 
is  tilted  toward  the  contracted  muscles  while  the  chin  is  rotated 
in  the  opposite  direction.  The  spasm  and  contraction  of  the 
affected  muscles  are  apparent,  and  direct  tension  upon  them  is 
painful.  If,  however,  the  tension  is  relaxed  by  inclining  the 
head  toward  the  contraction,  movement  of  the  head  in  other  direc- 
tions will  be  found  to  be  practically  unrestricted. 

In  Pott's  disease  the  spasm  of  muscles  is  general,  the  deformity 
is  not  of  a  regular  type,  since  the  chin  often  points  to  the  side 
toward  which  the  head  is  inclined.  Steady  tension  with  the  aim 
of  reducing  the  deformity  is  not,  as  a  rule,  painful ;  in  fact,  it  is 
often  agreeable  to  the  patient.  Finally  the  limitation  of  motion 
cannot  be  lessened  by  inclining  the  head  toward  the  muscle  that 
seems  to  be  most  contracted,  for  the  reflex  spasm  of  Pott's  disease 
limits  motion  in  every  direction.  As  a  rule,  the  diagnosis  is 
easily  made,  but  in  cases  complicated  by  suppuration  of  the  cer- 
vical glands  it  is  sometimes  impossible  to  exclude  Pott's  disease 
until  after  the  effect  of  treatment  has  been  observed. 

Disease  of  the  cervical  spine,  other  than  tuberculous,  is  com- 
paratively rare,  and  resembles  in  its  symptoms  Pott's  disease 
rather  than  torticollis.  Arthritis  of  the  atloaxoid  articulation 
may  be  a  manifestation  of  rlieumatism  ;  it  may  follow  infectious 
disease,  or  it  may  occur  as  an  isolated  infection.  It  is  of  sudden 
onset,  and  it  resembles  acute  spastic  torticollis,  except  that  all  the 
surrounding  muscles  are  affected  rather  than  a  particular  group ; 
in  fact,  but  for  the  liistory  it  could  not  be  distinguished  from 
tuberculous  disease  of  this  region. 

Although  the  diagnosis  of  torticollis  is  simple,  it  is  not  always 
easy  to  determine  the  muscle  or  muscles  involved  in  the  contraction. 

The  effect  of  unilateral  contraction  of  the  different  muscles  is 
as  follows : 

The  sternomastoid  inclines  the  head  toward  the  contraction, 
displaces  it  toward  the  opposite  shoulder,  elevates  the  chin,  and 
turns  it  away  from  the  contracted  muscle. 


636  ORTHOPEDIC  SURGERY. 

The  trapezius  has  much  the  same  action,  but  the  backward 
inclination  and  rotation  are  more  marked. 

The  action  of  the  complex  us  resembles  that  of  the  trapezius, 
but  the  rotation  is  less. 

The  splenius  inclines  the  head  backward  and  toward  the  con- 
tracted muscle,  but  does  not  turn  the  chin  in  the  opposite  direction. 

The  scaleni  have  the  same  action,  except  that  the  head  is 
inclined  forward. 

As  has  been  stated,  in  acute  torticollis  several  muscles  are 
often  involved,  but  the  spasm  is  usually  greater  in  one  or  in  one 
group  than  in  another.  The  seat  of  greatest  contraction  may  be 
determined  by  the  deformity,  by  the  evident  spasm  that  resists 
reposition,  and  by  the  local  sensitiveness  on  palpation.  As  a 
rule,  when  the  primary  contraction  is  of  the  posterior  group,  the 
deformity  is  more  marked  than  in  other  forms.  Bilateral  con- 
traction of  the  muscles  is  rare,  but  it  is  occasionally  seen  (Fig. 
372). 

Treatment.  The  treatment  varies  according  to  the  cause  and 
with  the  duration  of  the  deformity.  Excluding,  for  the  present, 
the  rare  and  irregular  forms  of  wryneck  there  are,  from  the 
remedial  standpoint,  two  forms  of  torticollis : 

1.  The  chronic  form,  in  which  the  local  pain  and  sensitiveness 
are  absent,  but  in  which  there  is  resistant  and  permanent  defor- 
mity. As  has  been  stated,  congenital  torticollis  is  included  in  this 
class. 

2.  The  acute  form,  in  which  the  distortion  is  of  short  duration 
and  in  which  permanent  contraction  may  be  prevented. 

The  Treatment  of  Chronic  Torticollis.  By  Manipulation.  Con- 
genital torticollis,  if  of  moderate  degree,  can  be  overcome  in  early 
infancy  by  methodical  stretching  of  the  contracted  parts.  One 
person  fixes  the  arm  and  another  draws  the  head  gently  but  firmly 
in  the  direction  opposed  to  the  contraction,  over  and  over  again, 
meanwhile  massaging  the  tissues  of  the  neck.  The  procedure 
should  be  repeated  several  times  a  day;  it  causes  slight  mo- 
mentary discomfort  if  properly  performed,  but  this  ceases  when 
the  stretching  is  discontinued.  Care  should  be  taken  also  that 
the  posture  may,  as  far  as  possible,  favor  the  reduction  of  the 
deformity ;  thus  while  the  child  is  in  the  mother's  arms  the  head 
should  be  supported,  and  when  asleep  the  pillow  may  be  arranged 
in  a  manner  to  prevent  the  improper  position.  In  this  way  the 
torticollis  may  be  entirely  corrected  or  its  progress  may  be  checked 
until  more  effective  treatment  is  indicated. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  637 

Hsematoma.  The  evidence  of  injury  at  birth  should  be  treated 
by  massage  with  some  bland  ointment ;  if  it  is  accompanied  by 
deformity  the  manipulation  already  described  should  be  employed. 

In  the  great  majority  of  cases  of  congenital  torticollis  the 
patient  is  not  brought  for  treatment  until  the  deformity  has 
become  an  eyesore  to  the  parents.  The  contracted  muscle  is  then 
usually  an  inch  shorter  than  its  fellow,  the  disparity  increasing, 
as  a  rule,  with  the  growth  of  the  child.  In  such  cases  the  imme- 
diate correction  of  the  deformity  is  indicated,  and  this  implies  in 
most  instances,  division  of  the  contracted  parts  by  subcutaneous 
tenotomy  or  by  open  incision. 

By  Subcutaneous  Tenotomy.  If  the  deformity  is  comparatively 
slight  and  if  the  contraction  seems  to  be  limited  to  the  sterno- 
mastoid,  and  particularly  to  its  sternal  portion,  one  may  hope  to 
overcome  the  most  resistant  part  of  the  contraction  by  the  sub- 
cutaneous operation.  Aside  from  the  possibility  of  wound  infec- 
tion, which  at  the  present  time  is  an  argument  of  very  little 
weight,  subcutaneous  tenotomy  has  the  advantages  of  simplicity, 
apparent  freedom  from  the  danger  which  parents  associate  with 
an  operation^  and  it  leaves  no  scar  behind.  It  is  inadequate, 
however,  for  the  correction  of  advanced  cases. 

The  patient  and  the  instruments  having  been  prepared  as  for  an 
ordinary  operation,  a  sand-bag  is  placed  beneath  the  shoulders  and 
the  head  is  inclined  so  that  the  contracted  muscle  is  thrown  into 
relief  beneath  the  skin.  The  sternal  insertion  of  the  tendon  is 
seized  with  two  fingers  and  the  tenotome  is  inserted  beside  it  and 
passed  beneath  it  at  a  point  about  an  inch  above  the  sternum. 
It  is  then  divided  by  a  sawing  motion  of  the  knife.  Division  of 
this  part  of  the  muscle  in  this  situation  is  practically  free  from 
danger,  and  in  the  slighter  degrees  of  deformity  one  can  by 
vigorous  manipulation  and  forcible  traction  overcome  the  resist- 
ance offered  by  the  other  tissues.  If  bands  of  fascia  resist  the 
correction,  they  may  be  divided  by  superficial  nicking  with  the 
tenotome  in  the  lateral  region  of  the  neck.  As  a  rule,  however, 
in  cases  of  this  type  the  open  incision  is  to  be  preferred,  as  it 
allows  the  opportunity  for  free  division  of  the  contracted  parts 
with  less  danger  of  injury  to  the  bloodvessels  and  nerves  in  this 
neighborhood. 

By  the  Open  Method.  The  incision  should  be  made  in  the  line 
of  the  muscle  midway  between  the  sternal  and  clavicular  inser- 
tion. In  the  milder  cases  in  childhood  it  need  be  little  more 
than  an  inch   in  length.     A  director  may  be  passed  beneath  the 


638 


ORTHOPEDIC  SURGERY. 


teudon,  and  on  this  it  may  be  divided.  The  clavicular  insertion 
and  the  non-resistant  bands  of  fascia  may  be  divided  as  they 
appear. 

In  cases  of  very  great  deformity  in  the  adult  some  of  the  pos- 
terior as  well  as  the  lateral  muscles  are  involved.  In  such 
instances  the  contracted  parts  may  be  divided  at  the  upper  border 
of  the  neck  through  an  incision  from  the  mastoid  process  back- 
ward along  the  lower  border  of  the  scalp,  the  scar  being  concealed 
by  the  hair. 

Overcorrection  of  the  Deformity.  The  object  of  treatment  is 
not  only  to  straighten  the  head,  but  also  to  overcome  all  restric- 


FlG.  374. 


Torticollis,  left,  showing  the  method  of  fixing  the  head  in  the  overcorrected 
position.    After  operation. 


tion  of  motion  that  may  remain  after  the  division  of  the  more 
resistant  parts,  and  the  operation,  whether  open  or  subcutaneous, 
must  be  supplemented  by  a  vigorous  kneading  of  the  lateral 
tissues  with  the  ulnar  border  of  the  hand  while  traction  is  made 
upon  the  arm  and  head.     Finally,  the  head  is  rotated  away  from 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  639 

the  contracted  parts,  the  aim  being  to  completely  overcome  the 
secondary  curvature  of  the  cervical  spine. 

It  may  be  stated  that  Lorenz  considers  it  possible  to  correct 
torticollis,  even  of  long  standing,  by  this  system  of  systematic 
kneading  and  stretching  without  previous  division  of  the  con- 
tracted tissues,  but  the  use  of  so  much  force  appears  to  be  unde- 
sirable if  by  so  slight  an  operation  it  may  be  avoided. 

iSTot  only  should  all  resistance  be  overcome  by  vigorous 
manipulation  at  the  time  of  operation,  but  the  head  should  be 
fixed  during  the  process  of  repair  in  the  overcorrected  position. 
Thus  in  the  treatment  of  typical  torticollis  the  chin  should  be 
turned  to  a  point  over  the  middle  of  the  clavicle  on  the  operated 
side,  and  the  head  should  be  inclined  toward  the  opposite  shoulder. 
In  this  attitude  a  plaster  bandage  should  be  applied  surrounding 
the  head  and  the  thorax.  This  bandage  should  remain  until  all 
local  sensitiveness  has  disappeared,  and  until  the  tendency  toward 
deformity  has  been  checked.  This  fixation  in  the  overcorrected 
position  is  very  important  in  childhood,  as  an  aid  in  overcoming 
the  deformity  habit,  but  it  may  be  dispensed  with  in  the  treatment 
of  adults  (Fig.  374). 

The  plaster  bandage  is  retained  from  four  to  eight  weeks. 
When  it  is  removed  massage,  manipulation,  and  gymnastic  train- 
ing are  indicated.  Twice  a  day  the  head  should  be  forced  to 
the  extreme  limit  of  overcorrection.  Traction  on  the  neck  in 
self-suspension  by  means  of  the  sling  used  in  the  application  of 
the  plaster  jacket,  a  regular  system  of  exercises  for  the  muscles 
of  the  neck  and  back,  and  supervision  of  the  habitual  postures  will 
usually  assure  a  complete  cure.  If,  however,  the  deformity  habit 
is  strong  so  that  the  head  has  a  marked  tendency  to  resume  the 
former  attitude,  some  support  is  indicated.  A  simple  and  effec- 
tive support  is  the  jury  mast  as  used  in  the  treatment  of  Pott's 
disease  with  the  plaster  jacket  or  attached  to  a  brace.  In  the 
treatment  of  children  a  band  of  elastic  tape  arranged  to  draw  the 
head  toward  the  shoulder  as  suggested  by  Sayre,  or  a  Thomas 
collar,  may  be  sufficient. 

As  has  been  stated,  the  necessity  for  support,  provided  the 
deformity  has  been  thoroughly  overcorrected,  depends  upon  the 
care  that  is  to  be  exercised  in  the  after-treatment.  When  exer- 
cises and  massage  can  be  efficiently  employed,  the  support  is  not 
essential.  In  other  cases  it  may  be  worn  for  several  months  with 
advantage. 

Tlie  priijciples  of  the  treatment  of  the  chronic  or  painless  form 


640  ORTHOPEDIC  SURGERY. 

of  torticollis  that  have  been  outlined  apply  to  the  acquired  as 
well  as  to  the  congenital  form,  when  adaptive  shortening  has 
replaced  active  contraction.  Acquired  torticollis  is,  in  most 
instances,  however,  a  preventable  deformity ;  thus  operative 
treatment  would  be  rarely  required  had  the  patient  received 
proper  treatment. 

The  Treatment  of  Acute  Torticollis.  The  insignificant  form  of 
torticollis  called  stiff  neck  may  be  treated  by  hot  applications  ;  a 
firm,  thick  collar  of  flexible  cotton  stiffened  by  several  layers  of 
adhesive  plaster  is  an  agreeable  support  in  the  more  painful  cases. 

In  true  acute  spastic  torticollis  the  cramp-like  contraction  of 
the  muscles  is  secondary  to  irritation  elsewhere.  This  one 
should  always  try  to  remove,  and,  as  has  been  stated,  the  general 
condition  of  the  patient  may  require  treatment  as  well.  But  the 
important  indication  is  to  support  the  head  in  order  to  relieve 
the  pain  and  to  correct  the  distortion.  In  the  early  stage  the 
support  of  the  collar  that  has  been  described  may  be  sufficient, 
but,  as  a  rule,  patients  of  this  class  are  not  seen  until  the  distor- 
tion has  persisted  for  weeks  or  months  even,  so  that  a  more 
efficient  form  of  support  is  required — such  is  the  plaster  jacket 
and  jury  mast.  The  elastic  tension  of  this  appliance  overcomes 
the  spasm  and  relieves  the  discomfort  and  apprehension  which 
have  lowered  the  vitality  of  the  patient  (Fig.  53).  If  the 
spasm  is  the  result  of  the  irritation  of  enlarged  or  suppurating 
cervical  glands,  as  is  often  the  case,  the  rest  afforded  by  the  brace 
is  an  effective  treatment  of  the  cause  as  well  as  of  its  effect,  and 
if  suppuration  is  present  this  support  is  most  convenient  for  the 
dressing  that  may  be  required.  When  the  acute  symptoms  and 
deformity  have  been  relieved  manipulation  and  exercises  may  be 
employed  in  the  manner  already  described. 

In  cases  of  longer  standing,  particularly  when  the  posterior 
muscles  are  involved,  the  deformity  may  be  forcibly  corrected 
under  anaesthesia,  and  the  head  may  then  be  fixed  in  a  plaster 
dressing  in  the  manner  already  described.  This  treatment  may 
be  employed  at  an  earlier  stage  in  selected  cases.  As  a  rule, 
when  deformity  has  been  allowed  to  persist  for  six  months  or 
more,  its  rectification  will  require  division  of  the  more  resistant 
tissues. 

Spasmodic  Torticollis. 

Spasmodic  torticollis,  a  form  of  convulsive  spasm  of  the 
muscles  of  the  neck  that  is  somewhat  similar  in  its  general  char- 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  641 

acteristics  to  writer's  cramp/  must  not  be  confounded  with  the 
acute  torticollis  of  childhood,  in  which  tonic  spasm  of  the  affected 
muscles,  due  usually  to  some  well-defined  irritation  of  the 
peripheral  nerves,  is  the  characteristic.  Spasmodic  torticollis  is 
an  affection  of  adult  life.  Of  32  cases  collected  by  Richardson 
and  Walton,^  but  2  were  in  patients  less  than  twenty  years  of 
age.  The  sexes  are  equally  liable  to  the  affection,  and  the  con- 
traction is  as  frequent  on  one  side  as  on  the  other. 

The  onset  of  the  affection  is  usually  gradual.  The  first  symp- 
toms are  often  sensations  of  stiffness  and  discomfort  in  the 
muscles  of  the  neck;  a  ^'  drawing  sensation"  and  a  momentary 
twitching  or  slight  contraction  which  draws  the  head  to  one  side. 
These  symptoms  increase  slowly  until  the  head  is  habitually 
inclined  in  the  attitude  of  torticollis.  For  a  time  the  patient  can 
correct  the  position  voluntarily,  or  by  supporting  the  head  with 
the  hand  can  restrain  the  twitching  of  the  muscles,  but  in  well- 
established  cases  the  head  is  persistently  inclined  to  one  side  and 
the  convulsive  spasm  is  uncontrollable.  This  latter  symptom  is 
the  most  marked  peculiarity  of  the  affection  ;  at  intervals  the  head 
begins  to  twitch,  and  it  is  finally  drawn  by  the  convulsive  con- 
traction of  the  muscles  into  an  attitude  of  extreme  deformity. 
As  the  muscles  most  often  affected  are  the  sternomastoid  and 
trapezius  the  attitude  is  usually  one  of  typical  torticollis.  The 
spasmodic  clonic  contractions  may  involve  the  muscles  of  the 
face  or  of  the  chest  even.  They  are  more  marked  when  the 
patient  is  excited  or  when  sudden  movements  are  necessary.  As 
a  rule,  patients  complain  of  neuralgic  pain  in  the  head  and  neck, 
aggravated  by  the  cramp-like  contractions. 

Etiology  and  Pathology.  The  etiology  is  obscure.  Many  of 
the  patients  present  a  neurotic  family  or  personal  history,  and 
overwork,  shock  to  the  nervous  system,  and  the  like  are  cited  as 
predisposing  causes.  The  affection  has  been  compared  to  writer's 
cramp,  as  in  certain  instances  the  spasm  appeared  to  be  caused  by 
constrained  positions  of  the  head  necessitated  by  certain  occupa- 
tions, aggravated,  it  may  be,  by  the  strain  of  defective  eyesight. 

The  affected  muscles  may  be  hypertrophied  from  constant 
activity,  and  in  the  later  stages  of  the  affection  they  are,  as  a 
rule,  permanently  shortened.  No  characteristic  changes  in  the 
nerves  or  in  the  central  nervous  system  have  been  recorded. 

'  Spasmodic  torticollis  is  definerl  by  Walton  as  a  "  disorder  of  the  cortical  ceutres  for  rota- 
tion of  the  head."    American  Journal  of  the  Medical  Sciences,  Marcli,  1898. 
2  American  .Journal  of  the  Medical  Sciences,  .January,  1895. 

41 


642  ORTHOPEDIC  SURGERY. 

Prognosis.  There  is  little  tendency  toward  spontaneous 
recovery.  As  a  rule,  the  spasm  becomes  more  constant  and  other 
muscles  become  involved. 

Treatment.  It  is  perhaps  unnecessary  to  state  that  the 
general  condition  of  the  patient  and  the  possible  local  and 
general  causes  of  the  spasm  should  receive  consideration.  As  a 
rule,  however,  the  patient  will  have  exhausted  both  constitutional 
and  local  treatment  before  coining  under  observation. 

In  the  mild  and  early  cases  the  avoidance  of  predisposing 
causes  combined  with  massage,  systematic  muscle  training,  and 
in  exceptional  instances  mechanical  support  may  be  of  service ; 
but  in  the  chronic,  severe,  and  persistent  cases  of  this  class  the 
resection  of  nerves  supplying  the  affected  muscles  has  alone  proved 
to  be  efficient.  If  the  spasm  is  limited  to  the  sternomastoid  and 
trapezius  muscles,  resection  of  the  spinal  accessory  nerve  may  be 
sufficient ;  but  if  other  muscles  are  involved  or  if  the  spasm  recurs 
after  the  original  operation,  the  removal  of  the  posterior  branches 
of  the  upper  cervical  nerves,  together  with  extensive  division  of 
the  contracted  muscles  upon  the  same  side  and  sometimes  upon 
the  opposite  side  also,  may  be  required. 

Eesection  of  the  spinal  accessory  nerve  was  first  performed  by 
Campbell  de  Morgan,  of  London,  in  1866,  and  since  then  the 
operation  has  been  repeated  many  times  by  other  surgeons  with 
temporary  or  permanent  benefit  to  the  patients.  According  to 
Petit,  of  26  patients  so  treated  13  were  cured  and  7  were  perma- 
nently improved.  In  5  others  the  benefit  was  but  temporary, 
and  1  died  from  erysipelas  following  the  operation.^ 

The  Operation.  The  spinal  accessory  nerve  passes  downward 
and  backward  from  the  jugular  foramen  and  enters  the  anterior 
border  of  the  sternomastoid  muscle  at  a  point  about  one  and  a 
half  inches  below  the  tip  of  the  mastoid  process.  At  this  point 
it  should  be  exposed.  Dr.  E.  Eliot,  Jr.,  from  a  special  study  of 
the  course  and  relations  of  the  nerve,  suggests  the  following 
method  :^ 

''  The  incision  should  be  generous,  for  the  nerve  is  situated  at 
a  considerable  depth,  and  should  extend  from  the  mastoid  process 
above  downward  to  one  or  two  inches  beyond  the  angle  of  the 
jaw.  The  anterior  edge  of  the  sternomastoid  should  then  be 
exposed.  In  the  upper  part  of  the  wound  the  posterior  and 
inferior  portion   of  the  parotid  gland   may   have  to  be  drawn 

1  L'Union  M6dicale,  July  9, 1897.  2  Annals  of  Surgery,  May,  1895. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  643 

forward,  although  usually  it  does  not  overlap  the  muscle.  When 
this  is  done  it  is  comparatively  easy  to  expose  by  blunt  dissection 
the  transverse  process  of  the  atlas,  as  it  lies  directly  below  the 
mastoid  process  above,  while  immediately  in  front  of  this  bony 
prominence,  and  running  downward  and  forward  from  the  mas- 
toid process  toward  the  angle  of  the  jaw  is  the  posterior  belly  of 
the  digastric.  Behind  this  lie  the  main  vessels  of  the  neck,  with 
the  spinal  accessory  nerve  emerging  from  the  jugular  foramen, 
and  the  operator  is  certain  that  no  harm  can  be  done  to  these 
structures  as  long  as  he  remains  superficial  to  the  digastric  belly, 
which  in  its  turn  lies  at  a  considerable  depth — in  fact,  at  about 
the  level  of  the  transverse  process  of  the  atlas. 

''  Owen  and  P^tit  have  drawn  attention  to  the  fact  that  the 
nerve  usually  enters  the  mastoid  muscle  at  a  point  opposite  the 
angle  of  the  jaw.  I  have  found,  however,  in  a  large  majority  of 
cases  that,  on  leaving  the  internal  jugular  it  assumes  a  definite 
relationship  with  the  transverse  process  of  the  atlas.  Never 
above  it,  sometimes  directly  over  it,  usually  a  fraction  of  an  inch 
in  front  of  its  most  prominent  part,  the  nerve  may  easily  be 
detected  in  the  small  amount  of  connective  tissue  that  envelops 
it,  and  from  this  point  to  its  entrance  into  the  belly  of  the  muscle 
it  may  be  isolated  with  safety,  and  treated  by  any  suitable  pro- 
cedure. If,  exceptionally,  it  should  escape  detection,  the  anterior 
border  of  the  muscle  should  be  drawn  sharply  backward  at  a 
point  opposite  the  angle  of  the  jaw,  the  nerve  in  this  way  put  on 
the  stretch,  and  by  blunt  dissection  in  the  adipose  tissue  that 
separates  the  under  surface  of  the  muscle  from  the  sheath  of  the 
vessels  the  nerve  may  be  readily  exposed.  Usually  the  nerve 
passes  from  under  the  posterior  belly  of  the  digastric,  at  a  point 
just  in  front  of  the  transverse  process  of  the  atlas,  to  a  point  on 
the  deep  surface  of  the  muscle  just  behind  its  anterior  margin 
opposite  the  angle  of  the  inferior  maxilla.  It  is  sometimes  accom- 
panied by  a  small  artery  and  vein,  the  latter  easily  visible,  the 
former  a  branch  of  the  occipital.  Rarely  the  nerve  lies  at  a  con- 
siderable distance  from  the  transverse  process  of  the  atlas  ;  in  one 
case  as  much  as  half  an  inch  anteriorly.  Here  the  nerve  could 
be  found  at  its  entrance  into  the  muscle,  the  landmark  of  the 
transverse  process  having  failed  to  localize  its  situation." 

Richardson  suggests  that  if  the  nerve  is  not  readily  found  its 
position  may  be  ascertained  by  drawing  the  finger-nail  firmly 
across  the  bottom  of  the  wound,  a  sharp  contraction  following 
pressure  upon  it.     The  nerve;  having  been  isolated  a  section  of  an 


644  ORTHOPEDIC  SURGERY. 

inch  should  be  removed.  Richardson  advises  in  addition  vigor- 
ous stretching  of  both  extremities.  After  division  of  the  nerve 
the  spasmodic  contraction  relaxes  and  the  muscles  become  flaccid, 
allowing  the  head  to  be  brought  to  the  normal  position,  or  if  the 
deformity  has  become  permanent  the  contracted  parts  may  be 
divided  as  in  the  ordinary  form.  Fixation  of  the  head  is  not,  as 
a  rule,  required.  The  operation  should  be  supplemented  by 
massage  and  by  muscle-training.  If  the  spasm  has  been  confined 
to  the  muscles  supplied  by  the  spinal  accessory  nerve,  the  treat- 
ment may  be  permanently  successful,  but  in  many  instances  the 
spasm  may  recur  in  other  muscles.  Of  these,  the  posterior  group 
of  the  opposite  side  is  more  often  affected,  and  a  similar  opera- 
tion for  resection  of  the  posterior  branches  of  the  upper  cervical 
nerves  may  be  indicated.  This  has  been  performed  with  success 
by  Smith,  of  Loudon  ;  Keen,  Richardson,  and  others.  According 
to  Smith/  the  operation  should  be  conducted  as  follows  :  An 
incision  is  carried  downward  from  the  occiput  about  three  inches 
in  length,  parallel  to  and  one  inch  from  the  spinous  processes.  It 
is  continued  through  the  trapezius  to  the  edge  of  the  splenius. 
The  complexus  is  then  divided  and  the  posterior  branches  of  the 
nerves  are  exposed  ;  those  of  the  three  upper  nerves  which  supply 
the  posterior  rotatars  are  then  resected. 

Keen^  operates  in  a  somewhat  different  manner,  by  a  transverse 
incision  two  and  a  half  inches  in  length  from  the  middle  line  of 
the  neck  on  a  level  with  a  point  one-half  an  inch  below  the  level 
of  the  lobule  of  the  ear.  The  trapezius  is  divided  transversely, 
afterward  the  complexus,  care  being  taken  to  spare  the  great 
occipital  nerve.  The  posterior  branch  of  the  second  cervical 
nerve  is  then  resected ;  the  suboccipital  nerve  is  then  looked  for 
in  the  suboccipital  triangle,  traced  down  to  the  spine,  and  divided. 
The  external  trunk  of  the  posterior  division  of  the  third  occipital 
nerve  is  then  exposed  below  the  great  occipital  and  divided  close 
to  the  bifurcation  of  the  nerve  trunk ;  thus  the  nerve  supply  of 
the  chief  posterior  rotators,  the  splenius  capitis,  the  rectus  capitis, 
posticus  major,  and  the  obliquus  inferior  is  removed. 

The  paralysis  that  follows  even  such  extensive  operations 
seems  to  inconvenience  the  patient  but  slightly,  while  the  relief 
from  deformity  and  from  the  constant  spasm  is  a  more  than  suffi- 
cient compensation  for  whatever  weakness  or  disability  may  result. 

The  following  are  the  conclusions  of  Richardson  and  Walton  •? 

1  Spasmodic  Wryneck,  London,  1891.  s  Annals  of  Surgery,  January,  1891. 

'^  Annals  of  Surgery,  January,  1891. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS.  645 

1.  Palliative  treatment,  whether  by  drugs,  apparatus,  or  elec- 
tricity, will  rarely  prove  successful  in  well-established  spasmodic 
torticollis. 

2.  Massage  may  prove  of  value  in  comparatively  recent  cases. 

3.  Resection  affords  practically  the  only  rational  remedy. 

4.  Operation  on  the  spinal  accessory  nerve  may  afford  relief, 
even  if  other  muscles  than  the  sternocleidomastoid  are  affected. 
On  the  other  hand,  the  affection  previously  limited  to  the  sterno- 
cleidomastoid may  spread  to  other  muscles  in  spite  of  this 
operation. 

5.  No  fear  of  disabling  paralysis  need  deter  us  from  recom- 
mending operation,  as  the  head  can  be  held  erect  even  after  the 
most  extensive  resection. 

6.  The  most  common  combination  of  spasm  is  that  involving 
the  sternomastoid  on  one  side  and  the  posterior  rotators  on  the 
other,  the  head  being  held  in  the  position  of  sternomastoid  spasm 
with  the  addition  of  retraction  through  the  greater  power  of  the 
posterior  rotators. 

7.  It  seems  advisable  in  most  cases  to  give  preference  to  the 
resection  of  the  spinal  accessory  as  the  preliminary  procedure. 

In  a  later  communication  Richardson  and  Walton^  report  very 
satisfactory  final  results  on  cases  treated  by  resection  of  nerves 
supplying  the  muscles  that  were  affected  by  the  spasm  on  one  or 
both  sides,  combined  with  complete  division  of  the  muscles  as 
well,  when  permanent  contraction  was  present. 

Kalmus'^  has  reviewed  the  literature  of  the  subject.  In  11 
cases  of  simple  stretching  of  the  spinal  accessory  nerve  3  were 
cured.  In  68  cases  the  nerve  was  resected  ;  of  these  23  were 
cured  and  20  were  improved.  In  4  there  was  no  improvement, 
and  in  1  the  patient  died.  In  15  cases  the  resection  of  the  nerve 
was  supplemented  by  division  of  cervical  nerves  ;  10  of  these 
were  cured  and  3  were  improved.  In  2  others  the  sternomastoid 
muscle  was  divided. 

Irregular  and  Exceptional  Forms  of  Torticollis. 

Paralytic  Torticollis.  One  or  more  of  the  muscles  of  the 
neck  may  be  paralyzed,  as  from  anterior  poliomyelitis,  and  thus 
a  deformity,  due  at  first  to  simple  weakness  and  later  to  the 
permanent  effects  of  the  disability,  may  be  the  result. 

'  American  Journal  of  the  Merllcal  Sciences,  1896. 

''  '/ait  Operatlv  liehand.  Caput.  Obst.  Spasticum,  Beitriige  zur  klin.  Chir.,  1900,  Brl.  .xxvi. 


646  ORTHOPEDIC  S UE GER  Y. 

Diphtheritic  Paralysis  and  Torticollis.  The  muscles  of  the 
neck  may  be  inYolved  in  paralysis  following  diphtheria.  In  this 
form  the  trapezii  muscles  are,  as  a  rule,  affected,  so  that  the 
head  hangs  forward,  but  occasionally  the  paralysis  may  be  accom- 
panied by  contraction  of  one  of  the  sternomastoids.  The  history, 
the  evident  weakness,  and  the  paralysis  of  the  soft  palate  or  other 
parts,  which  is  often  present,  usually  make  the  diagnosis  clear. 

Cervical  Opisthotonos.  In  the  course  of  certain  forms  of  dis- 
ease of  the  nervous  system,  for  example,  cerebrospinal  or  basilar 
meningitis,  the  head  may  be  drawn  backward  by  spasm  of  the 
posterior  muscles.  A  slight  degree  of  the  same  deformity  is 
sometimes  seen  in  ill-nourished  infants  not  suffering  from  serious 
disease.  This  and  the  preceding  distortion  are  of  some  impor- 
tance, because  they  may  be  mistaken  for  symptoms  of  Pott's 
disease  and  they  have  been  described  in  that  connection.  (See 
page  62.) 

Rhachitic  Torticollis.  During  the  course  of  acute  rhachitis, 
particularly  when  the  characteristic  deformity  of  the  lower  part 
of  the  spine  is  well  marked,  the  head  may  be  tilted  backward 
usually  as  a  compensatory  attitude,  but  occasionally  slight  spasm 
of  the  posterior  muscles  may  increase  the  distortion  ;  so,  also, 
when  lateral  deviation  of  the  spine  is  present  due  to  rhachitis  the 
neck  may  participate  in  the  deformity  as  in  other  forms  of  rotary 
lateral  curvature.  This  is  not  torticollis,  however,  in  the  proper 
sense. 

Ocular  Torticollis.  Several  cases  have  been  recorded  in  which 
the  head  was  habitually  held  in  a  distorted  attitude  because  of 
defective  vision  or  irregularity  in  the  action  of  the  muscles  of  the 
eyes.  This  is,  however,  rather  an  improper  attitude  than  a 
variety  of  true  torticollis^  (Fig.  154). 

Psychical  Torticollis.  A  distortion  of  the  head,  apparently 
due  to  the  inability  of  the  patient  to  control  the  muscles  of  the 
neck,  has  been  described  by  Brissaud.^  The  deformity  was  not 
due  to  muscular  spasm,  since  it  could  be  corrected  by  the  pressure 
of  a  finger  on  the  head.  The  condition  is  called  by  Brissaud  a 
local  paralysis  of  the  will — a  form  of  neurosis  allied  to  neuras- 
thenia, epilepsy,  and  functional  spasm. 

1  Medical  News,  June  11,  1898,  p.  772.  2  Thfese  de  Paris,  1894. 


CHAPTER  XX 


DISABILITIES  AND   DEFORMITIES  OF   THE  FOOT. 

General  Description  of  the  Foot  and  of  its  Functions. 

The  function  of  the  foot  is  twofold  :  to  serve  as  a  passive 
support  of  the  weight  of  the  body,  and  as  an  active  lever  to  raise 
and  propel  it.  For  the  proper  performance  of  these  functions 
the  foot  is  constructed  to  allow  elasticity  under  pressure,  and  an 
alternation  of  attitudes  under  strain,  that  protect  it  from  injury. 

The  Arches.  The  most  noticeable  peculiarity  of  the  foot  is 
the  arrangement  of  its  arches.  As  has  been  suggested  by  Ellis 
and  others,  the  construction  and  shape  of  the  arched  part  of  the 


Fig.  375. 


Longitudinal  section  of  the  cast  of  the  arch  at  the  point  A  in  Fig.  376.  A,  the  astragalo- 
scaphoid  junction  ;  B,  the  internal  tuberosity  of  the  os  calcis ;  C,  the  head  of  the  first  meta- 
tarsal bone. 

foot  may  be  better  understood  by  considering  it  as  half  of  the 
arch  formed  by  the  two  feet.  This  complete  arch  may  be  demon- 
strated by  making  an  imprint  of  the  apposed  feet  in  plaster  of 
Paris.  The  plaster  cast  which  represents  it  will  appear  in  shape 
somewhat  like  an  inverted  saucer,  tlie  part  of  each  foot  that  rests 
upon  the  ground  forming  half  of  an  irregular  ring.  If  the  plaster 
cast  is  sawed  into  equal  sections  it  will  be  seen  that  the  highest 
or  thickest  part  of  each  division  is  at  the  astragaloscaphoid  junc- 
tion ;  from  tin's  point  the  arch  descends  sharply  to  the  tuberosities 
of  the  OS  calcis,  and  gradually  to  the  outer  border,  beneath  the 
cuboid  l)one,  and  to  the  metatarsophalangeal  joints  (Fig.  375). 
A  cross-section  of  the  cast  will  show  the  contour  of  what  is  .some- 
times called  the  irn/iif>ver.^e  (irch.  (Fig.  o7()),  while  the  section 
through    the    long   diameter  will   demonstrate   the   shape  of  the 


648 


ORTHOPEDIC  SURGERY. 


longitudinal  arch.  In  descriptions  of  the  longitudinal  arch  it  is 
often  divided  into  two  parts,  of  which  the  outer  division  is  formed 
by  the  os  calcis,  the  cuboid,  and  the  two  outer  metatarsal  bones. 
Of  this  outer  arch,  the  highest  point  is  at  the  calcaneocuboid 
articulation  (Fig.  377),  and  although  it  is  normally  a  permanent 
arch,  yet  the  soft  tissues  are  forced  downward  beneath  it  when 


Fig.  376. 


Cross-section  of  the  cast  of  the  arches  of  the  apposed  feet.    A,  the  internal  and 
inferior  surface  of  the  astragalonavicular  junction. 

weight  is  borne,  so  that  the  outer  border  of  the  foot  makes  an 
imprint  throughout  its  entire  length,  as  contrasted  with  the  inner 
and  deeper  arch  formed  by  the  os  calcis,  the  astragalus,  the 
navicular,  the  cuneiform,  and  the  three  inner  metatarsal  bones 
(Fig.  378).  This  division,  although  an  artificial  one,  is  of  some 
service  in   calling  attention  to  the  fact  that  the  outer  or  lower 


Fig.  377. 


The  bones  of  the  right  foot,  viewed  from  the  outer  side.    (Testut,  from  Gerrish's  Anatomy. 


arch  is  more  solidly  braced,  and,  therefore,  better  adapted  for 
continuous  weight  bearing  than  is  the  higher  and  more  elastic 
inner  arch. 

The  diagram  of  the  longitudinal  arch,  showing  its  sharp 
descent  from  the  highest  point  to  the  centre  of  the  heel,  indicates 
that  the  heel  is  well  adapted  for  weight  bearing,  while  the  long 
anterior  pillar  composed  of  several  bones  is  less  strong  but  more 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     649 

elastic ;  thus  one  instinctively  extends  the  foot  in  descending 
stairs,  for  example,  to  avoid  the  unpleasant  jar  of  direct  shock 
received  upon  the  heel.  Of  this  anterior  pillar,  the  third  meta- 
tarsal bone  is  the  most  direct  support,  while  the  more  movable 
first  and  fifth  metatarsals,  more  under  muscular  control,  aid  in 
balancing  the  weight  and  sustaining  it  in  the  different  attitudes. 

Both  divisions  of  the  longitudinal  arch  are  permanent  arches, 
but  there  are  two  others  which  are  obliterated  under  weight — one 
of  these  is  that  formed  by  the  heads  of  the  metatarsal  bones,  the 
anterior  metatarsal  areh.  In  the  unweighted  foot  the  second  and 
third  metatarsal  bones  occupy  a  higher  plane  than  their  fellows, 
but  when  the  erect  posture  is  assumed  the  anterior  arch  is 
depressed  to  allow  all  the  metatarsal  heads  to  bear  their  share  of 
the  weight.     The  other  arch  does  not  rest  upon  the  ground,  but 

Fig.  378. 


The  bones  of  the  right  foot,  viewed  from  the  inner  side.    (Testut,  from  Gerrish's  Anatomy.) 


is  formed  by  the  internal  border  of  the  foot,  which  curves  slightly 
outward,  so  that  when  the  two  feet  are  placed  side  by  side  an 
interval  remains  between  them,  widest  at  the  highest  point  of  the 
longitudinal  arch,  as  is  shown  in  the  diagram  by  the  upright  sec- 
tion which  divides  the  cast  of  the  two  soles  from  one  another, 
the  inter-nal  arch  (Fig.  376).  When  the  weight  is  borne  this 
curved  contour  of  the  foot  becomes  straighter,  or  is  obliterated, 
or  is  even  transformed  to  an  arch  whose  convexity  is  internal 
(Fig.  :m). 

The  Foot  as  a  Passive  Support.  The  foot  is  supported  by 
the  muscles,  by  ligaments,  and  by  the  strong  plantar  fascia  that 
covers  in  the  sole.  When  the  foot  is  actively  used  it  is  in  great 
part  supported  by  the  muscles,  but  when  it  serves  as  a  passive 
support,  as  iu  standing,  tlie  ligaments  bear  the  greater  part  of  tlie 
strain,  and   its   normal   elasticity  allows  the   bearing  surface  to 


650  ORTHOPEDIC  SURGERY. 

expand  slightly  as  the  arches  are  slightly  depressed.  If  this 
normal  elasticity  is  diminished,  as  is  sometimes  the  case,  the  sup- 
ports of  the  arch  are  subjected  to  abnormal  pressure  and  the 
individual  may  suffer  from  sensitive  corns  or  calloused  skin 
beneath  the  bones  (Fig.  418).  Or  if  the  ligaments  allow  ab- 
normal expansion  the  arches  may  become  permanently  depressed, 
and,  as  a  result,  the  range  of  motion  necessary  to  the  proper 
functional  use  of  the  foot  may  be  permanently  restricted  (Fig. 
398). 

When  the  statement  is  made  that  the  foot  broadens  and  that  the 
arches  are  slightly  depressed  under  weight,  it  must  not  be  under- 
stood that  the  longitudinal  arch  is  simply  flattened  by  direct 
pressure  and  by  elongation  of  elastic  ligaments  and  fascia.  Liga- 
ments and  fascia  are  not  elastic  in  this  sense,  and  they  are  not,  in 
the  normal  foot,  overstretched.  The  change  in  contour  is  the 
effect  of  normal  motion  in  the  joints  of  the  foot,  by  which  it  is 
placed  in  the  most  favorable  attitude  for  weight  bearing  without 
muscular  exertion — the  so-called  attitude  of  rest. 

Of  the  changes  of  contour  that  distinguish  the  foot  used  as  a 
passive  support  from  the  one  that  bears  no  weiglit,  the  most 
significant  is  the  obliteration  of  the  outward  curve  of  its  internal 
border.  This  change  is  due  to  the  fact  that  the  astragalus,  bear- 
ing the  leg,  rotates  inward  and  downward  on  the  os  calcis  until 
it  is  checked  by  the  resistance  of  the  ligaments  and  by  the  inter- 
locking of  the  bones.  The  head  of  the  astragalus  thus  becomes 
slightly  prominent,  the  inner  border  of  the  foot  is  depressed,  and 
an  attitude  is  attained  in  which  the  weight  of  the  body  may  be 
supported  with  but  slight  muscular  exertion.  In  this  attitude  of 
rest,  as  von  Meyer  has  explained,  there  is  general  fixation  of 
joints  of.  the  lower  extremity  which  makes  support  possible  with 
the  least  muscular  exertion.  The  pelvis  tilts  slightly  backward 
until  tension  is  brought  upon  the  anterior  part  of  the  capsule  of 
the  hip-joint ;  the  femur  rotates  slightly  inward  on  the  tibia, 
which  in  turn  falls  slightly  inward  upon  the  everted  foot.  To 
unlock  the  joints  the  pelvis  must  be  tilted  forward  or  the  hip 
must  be  flexed. 

The  Foot  in  Activity.  The  second  function  of  the  foot  is  as 
a  lever  to  raise  and  to  propel  the  body.  The  calf  muscles  supply 
the  power  and  the  heads  of  the  metatarsal  bones  serve  as  the 
fulcrum  on  which  the  weight  is  to  be  lifted.  When  the  foot  is 
used  as  a  lever,  it  should  be  held  in  such  relation  to  the  leg  that 
the  line  of  weight,  passing  downward  through  the  centre  of  the 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      651 

knee  and  ankle-joints,  is  continued  over  the  second  toe  or  practi- 
cally the  centre  of  the  foot.  As  the  body  is  lifted  over  the 
fulcrum  the  leg  is  turned  outward  in  its  relation  to  the  forefoot, 
because  the  inner  side  of  the  fulcrum,  formed  by  the  first  meta- 
tarsal bone,  is  longer  than  its  outer  side  ;  thus  the  strain  is 
directed  toward  the  outer  and  stronger  side  of  the  foot  (Fig.  379). 

In  the  proper  walk,  which  is  the  best  illustration  of  the  lever- 
age function,  the  feet  should  be  held  practically  parallel  to  one 
another,  so  that  the  line  of  strain  may  fall  through  the  centre  of 
the  foot.  As  one  foot  is  advanced  it  first  bears  weight  momen- 
tarily on  the  heel,  then  upon  its  outer  border;  the  heel  is  then 
raised,  and  the  body  is  lifted  over  the  toes,  the  great  toe  giving 
the  final  impulse  to  the  step,  so  that  if  the  walker  is  looked  at 
from  behind  he  appears  to  be  in-toeing  at  the  termination  of 
each  step.  Thus,  during  the  walk,  there  is  an  alternation  of 
postures,  and  the  foot,  under  muscular  control,  assumes  the 
attitudes  most  opposed  to  that  of  passive  support. 

Improper  Postures.  The  alternation  of  postures  and  the  lever- 
age action  of  the  foot  are  by  no  means  necessary  to  simple 
progression ;  for  example,  both  feet  might  be  fixed  in  plaster 
bandages,  yet  walking  would  be  possible,  just  as  it  is  possible 
on  two  wooden  legs.  Indeed,  an  approximation  to  such  a  manner 
of  walking  is  often  seen,  in  which  the  feet  are  practically  held 
in  the  passive  attitude,  the  weight  being  borne  upon  the  heels. 
Such  a  walk  is  necessarily  jarring  and  ungraceful,  and  if  it  is 
not  the  result  of  weakuess  and  deformity  it  predisposes  to  them 
because  of  the  disuse  of  proper  function. 

One  means  of  making  the  leverage  function  difficult  is  the 
custom  of  turning  the  feet  outward.  Outward  rotation  of  the  feet 
is  normal  in  the  passive  attitude  of  weight  bearing,  because  it 
enlarges  the  base  of  support,  locks  the  joints,  and  throws  the  strain 
upon  the  ligaments  to  relieve  the  muscles.  On  this  very  account 
it  is  the  improper  attitude  for  activity  because  the  strain  falls 
upon  the  inner  border  of  the  foot,  or  to  the  inner  side  of  the  ful- 
crum, and  makes  the  proper  exercise  of  muscular  power  and 
alternation  of  postures  imjxjssible.  In  other  words,  the  attitude, 
normal  when  the  foot  is  used  as  a  passive  support,  is  abnormal 
when  it  is  in  active  use. 

The  Movements  of  the  Foot.  The  junction  between  the  foot 
and  the  leg  is  made  by  means  of  tlie  astragalus,  a  bone  which  is 
not  intimately  connected  with  either  part,  since  it  moves  upon 
the  leg  and  ii|)on  tli(!  foot,  and  to  it  no  muscles  are  attached. 


652 


ORTHOPEDIC  SURGERY. 


The  primary  movements  of  the  foot  are  four  in  number — dorsal 
flexion,  plantar  flexion,  adduction,  abduction. 

Simple  dorsal  and  plantar  flexion  are  confined  to  the  ankle- 
joint,  but  complete  plantar  flexion  is  combined  with  slight  adduc- 
tion, and  dorsal  flexion  with  abduction,  because  the  external  facet 
of  the  astragalus  allows  a  greater  range  of  motion  on  the  external 
malleolus  than  is  permitted  about  the  internal  malleolus. 

The  range  of  motion  at  the  ankle-joint  is  from  sixty  to  eighty 
degrees;  thus  dorsal  flexion  to  ten  or  twenty  degrees  less  than 


Fig.  379. 


Fig.  380. 


Illustrating  the  involuntary  adduction 
of  the  forefoot,  due  to  the  obliquity  of 
the  bearing  surface  of  the  metatarsus, 
in  the  proper  attitute  for  walking. 


The  improper  attitude  of  outward  rotation, 
in  which  there  is  disuse  of  the  leverage 
function. 


the  right  angle,  and  plantar  flexion  to  fifty  to  sixty  degrees  more 
than  the  right  angle  (Figs.  381  and  382). 

Adduction  and  abduction  of  the  foot  are  carried  out  in  the 
mediotarsal  and  subastragaloid  joints. 

Adduction,  the  motion  of  turning  the  foot  inward  in  its  relation 
to  the  leg,  is  always  accompanied  by  inversion  of  the  sole  or 
supination,  because  of  the  shape  of  the  joint  surfaces  between  the 
astragalus  and  os  calcis,  where  the  greater  part  of  the  motion 
takes  place.  Simple  adduction  and  abduction  without  supination 
or  pronation  is  possible  to  a  very  limited  extent  in  the  medio- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      653 

tarsal  joint.  Its  range  may  be  tested^  by  fixing  the  heel,  when 
the  forefoot  may  be  moved  slightly  from  side  to  side  upon  the 
astragalus  and  os  calcis.  The  range  of  motion  in  the  sub- 
astragaloid  joint  is  twice  as  free  as  in  the  mediotarsal  joint.  The 
character  of  the  motion  between  the  astragalus  and  os  calcis  is 
rotation  on  an  axis  passing  through  the  upper  and  inner  part  of 
the  head  of  the  astragalus,  downward]  and  outward  to  the  outer 
tuberosity  of  the  os  calcis.  Thus  for  all  practical  purposes 
adduction,  inversion,  and  supination  are  synonymous  terms,  as 
are  abduction,  pronation,  and  eversion. 


Fig.  381. 


Fig.  382. 


Voluntary  dorsal  flexion.  Voluntary  plantar  flexion. 

In  these  attitudes  the  astragalus  moves  with  the  foot  upon  the  leg  hones,  as  contrasted  with 

adduction  and  abduction,  in  which  the  centre  of  motion  is  helow  the  astragalus. 


In  the  movement  of  adduction-  of  the  foot  the  astragalus  is 
fixed  between  the  malleoli,  and  upon  it  the  os  calcis  glides  for- 
ward and  its  anterior  extremity  turns  slightly  inward ;  the 
sustentaculum  tali  moves  backward,  its  inner  superior  surface  is 
elevated,  and  its  external  surface  is  depressed.  Meanwhile  the 
forefoot,  following  the  motion  of  the  os  calcis,  is  carried  inward 
about  the  head  of  the  astragalus  ;  its  inner  border  is  elevated, 
and  its  outer  border  is  depressed,  so  that  the  sole  looks  inward 
and  downward.  In  this  attitude  all  the  arches  are  increased  in 
depth  (Fig.  383). 

In  abduction  the  bones  move  upon  one  another  in  the  reverse 


654 


ORTHOPEDIC  S UB GEB  Y. 


direction,  the  curves  are  lessened,  and  that  of  the  inner  border  is 
obliterated  (Fig.  384). 

The  extreme  of  adduction  is  only  attained  in  the  position  of 
plantar  flexion,  because  in  this  position  the  adduction  possible  at 
the  ankle-joint,  in  part  due  to  the  contour  of  the  astragalus  and 
in  part  to  the  greater  mobility  allowed  in  the  joint  when  the 
narrow  posterior  border  of  the  astragalus  is  alone  in  contact  with 


Fig.  383. 


Fig.  384. 


Voluntary  adduction.  Voluntary  abduction. 

In  these  postures  the  foot  moves  upon  the  astragalus,  which  is  practically  fixed  between 
the  malleoli.  Adduction,  the  turning  of  the  foot  inward  in  its  relation  to  the  leg,  is  always 
accompanied  by  elevation  of  its  inner  and  depression  of  its  outer  border.  This  is  known 
as  supination  or  inversion  of  the  foot.  The  reverse  of  this  attitude — pronation  or  eversion — 
is  an  accompaniment  of  abduction,  as  is  illustrated  in  the  figures. 

the  malleoli,  is  added  to  the  adduction  which  the  joints  of  the  foot 
permit. 

Extreme  abduction  is  attained  in  the  attitude  of  dorsal  flexion, 
its  extent  being  about  one-half  that  of  adduction ;  the  entire 
range  of  motion  between  the  two  extremes  being  about  forty-five 
degrees. 

In  this  description  the  foot  is  considered  as  moving  on  the 
leg,  but  in  the  attitude  of  rest  the  foot  becomes  the  fixed  point 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     655 

and  the  astragalus  moves  upon  the  os  calcis  in  the  manner  and  to 
the  position  already  mentioned  in  the  description  of  abduction — 


Pig.  385. 


Fig.  386. 


The  direct  dorsal  flexors. 

Tibialis  anterior  of  right  side  ;  outline  and  Peroneus  tertius  of  right  side  ;  outline  and 

attachment  areas.    (Gerrish.)  attachment  areas.    (Gerrish.) 

i.  e.,  it  slips  downward  and  forward  and  turns  inward,  and  at  the 
same  time  the  anterior  extremity  of  the  os  calcis  turns  slightly 


Fig.  387. 


Pig.  388. 


/,'      / 


The  calf  muscle.    The  plantar  flexor. 
Gastrocnemius  of  right  side  ;  outline  and  Soleus  of  right  side ;  outline  and  attach- 

attachment  areas.    (Gerrish.)  ment  areas.    (Gerrish.) 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     657 

inward  and  downward,  and  its  inner  border  is  depressed.     Corre- 
sponding to  this  movement,   as    the   inner  border  of  the  foot 


Fig.  389. 


Fig.  390. 


The  direct  abductors. 

pT/p^V^h^'  "/  "^'^^  ""'t^  '•  ''""*°®  P«^o°«"«  ^'^^'^  of  right  side  ;  outline  and 

and  attachment  areas.    (Gerrish.)  attachment  areas.     (Gerrlsh.) 

becomes  straight  or  bulges  inward,  the  navicular  is  forced  forward 
and  downward  and  the  longitudinal  arch  is  depressed.     As  has 

42 


658 


ORTHOPEDIC  SURGERY. 


Fig.  391. 


■\- 


The  most  important  adductor. 
Tibialis  posterior  of  right 
side  ;  outline  and  attachment 
areas.  The  most  of  the  muscle 
is  represented  as  if  seen 
through  the  bones.    (Gerrish.) 


been  mentioned,  the  turning  of  the  leg 
inward  and  the  corresponding  turning  of 
the  foot  outward  in  its  relation  to  it  locks 
in  a  manner  the  ankle-joint,  and  at  the 
same  time  throws  the  strain  upon  the  liga- 
ments, so  that  standing  in  the  erect  posture 
is  possible  with  but  little  muscular  exertion 
(Fig.  396). 

To  put  it  in  a  simpler  manner,  the  leg 
supporting  the  weight  of  the  body  has  a 
tendency  to  tilt  the  foot  over  toward  the 
inner  side  and  to  evert  the  sole ;  thus,  un- 
der increasing  superincumbent  weight,  the 
point  of  greatest  pressure  on  the  sole  shifts 
from  its  centre  and  outer  border  toward 
the  inner  border.  If,  on  the  other  hand, 
the  body  is  raised  upon  the  toes,  the  arch 
is  relieved  from  strain  and  the  weight  falls 
upon  the  front  and  outer  part  of  the  foot. 
Plantar  flexion  and  adduction  represent, 
as  contrasted  with  the  passive  attitude  of 
supporting  weight,  the  attitude  of  activity 
in  which  the  foot  is  supported  and  con- 
trolled by  the  muscles. 

The  Function  of  the  Muscles.  The 
most  important  function  of  the  dorsal 
flexors  is  to  lift  the  foot  as  it  is  swung  for- 
ward of  the  plantar  flexors,  to  serve  in  the 
active  propulsion  of  the  body.  The  differ- 
ence in  function  is  shown  by  the  relative 
strength  of  the  two  groups,  the  plantar 
flexors  being  five  times  the  stronger;  in 
fact,  the  calf  muscle  (gastrocnemius  and 
soleus)  alone  is  three  times  as  strong  as  all 
the  other  muscles  of  the  foot  combined. 
It  is  practically  the  leverage  muscle,  the 
others  serving  more  especially  to  fix  and  to 
hold  the  forefoot,  or  fulcrum,  in  its  proper 
relation  to  the  leg.  It  is  also  a  powerful 
adductor  and  supinator  of  the  foot  in  the 
attitude  of  plantar  flexion  (Figs.  387  and 
388). 

The  muscles  that  most  directly  support 
the  inner  arch  of  the  foot  are  the  tibialis 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      659 

posticus  and  tibialis  anticus,  whose  tendons  meet  in  their  in- 
sertions in  front  of  the  astragalus  in  the  form  of  a  V.  The 
tibialis  anticus  supports  the  internal  border  of  the  foot  from 
above,  and  is  the  direct  supinator  of  the  foot  in  dorsal  flexion 
— that  is,  if  unopposed  it  elevates  the  inner  border  of  the  foot, 
when  it  acts  as  a  dorsiflexor.  The  tibialis  posticus  is  the  most 
powerful  adductor  (Figs.  385  and  391).  The  extensor  longus 
hallucis  is  an  adjunct  of  the  tibialis  anticus  in  its  action  on  the 
foot  as  a  whole.  The  extensor  longus  digitorum,  including  the 
peroneus  tertius,  is  a  dorsal  flexor  and  abductor. 

The  flexor  longus  hallucis,  passing  directly  beneath  the  sus- 
tentaculum tali,  aids  in  supporting  the  weak  part  of  the  foot  and 
its  position  demonstrates  the  importaace  of  the  proper  functional 
use  of  the  great  toe  (Fig.  395). 

The  peroneus  longus  and  brevis  support  the  outer  arch,  and 
the  former  binds  the  foot  together  and  holds  the  great  toe  firmly 
against  the  ground ;  thus  it  indirectly  supports  the  longitudinal 
arch  against  direct  pressure  (Figs.  389  and  390).  They  also  serve 
as  abductors  and  pronators. 

The  relative  strength  of  the  muscles  and  their  functions  is 
shown  in  the  following  tables  •} 

Dorsal  Flexors  of  the  Foot;  Strength  Reckoned  in  Kilo- 
grammetres. 

Tibialis  anticus 0.871 

Extensor  longus  digitorum 0.280 

Extensor  longus  pollicis 0.155 

Peroneus  tertius 0.087 

1.393 

Plantar  Flexors. 

The  calf  f  Soleus 3.256 

muscle,   t  Gastrocnemius 2.831 

Flexor  longus  pollicis 0.218 

Peroneus  longus 0.118 

Tibialis  posticus  0.094 

Flexor  longus  digitorum 0.078 

Peroneus  brevis 0.055 

6.650 

Relative  Strength  of  the  Supinators  of  the  Sdbastragaloid 

Joint. 

Weight  of  the 
Strength.  muscles. 

Soleus 1.021  157.0  grammes. 

Gastrocnemius 0.709  120.0        " 

Tibialis  posticus 0.337  39.6        " 

Flexor  longus  jjollicis 0.172  33.2        " 

Flexor  longus  digitorum 0.123  12.3        " 

2.362  362.1         " 

'  Ueber  die  Arbeitsleistung  der  auf  die  Fussgelenke  Wirkenden  Muskeln,  R.  Fick,  Leipzig, 
1892. 


660  ORTHOPEDIC  SURGERY. 


Relative  Strength  of  the  Pronators  of  the  Subastragaloid 

Joint. 

Weight  of  the 
Strength.  muscles. 

Peroneus  longus 0.282  24.0  grammes. 

Peroneus  brevis 0.192  16.5        " 

Extensor  longus  digitorum        ....    0.164  18.2        " 

Peroneus  tertius .    0.067  3.5        " 

Extensor  longus  pollicis 0.045  12.3        " 

Tibialis  anticus .0  021  49.2        " 

0.771  123.7        " 

Relative  Strength  of  the  Supinators  of  the  Mediotarsal  Joint. 

Tibialis  anticus 0.238 

Tibialis  posticus 0,078 

Flexor  longus  pollicis 0.034 

Flexor  longus  digitorum 0.033 

Extensor  longus  pollicis 0.030 

0.413 

Relative  Strength  of  the  Pronators  of  the  Mediotarsal  Joint. 

Peroneus  longus 0.162 

Peroneus  brevis 0.090 

Extensor  longus  digitorum 0.085 

Peroneus  tertius 0.033 

0.370 

It  will  be  noticed  that  the  strength  of  the  pronators  and 
supinators  (abductors  and  adductors)  of  the  mediotarsal  joint  is 
nearly  equal,  and  that  the  great  preponderance  of  power  of  the 
supinators  of  the  subastragaloid  joint  is  owing  to  the  fact  that  the 
calf  muscle  is  a  supinator.  When  the  foot  is  at  a  right  angle 
with  the  leg,  the  power  of  the  calf  muscle  not  being  utilized,  the 
pronators  are  stronger  than  the  supinators.  It  will  be  noticed,  also, 
that  the  tibialis  anticus  muscle,  which  supinates  the  mediotarsal 
joint,  is  reckoned  among  the  pronators  of  the  subastragaloid  joint. 

The  Foot  Considered  as  a  Mechanism.  In  the  study  of  the 
deformities,  and  particularly  of  the  functional  weaknesses  of  the 
foot,  one  must  never  lose  sight  of  the  fact  that  it  is  a  mechanism, 
subject  to  mechanical  laws,  and  that  its  deformities  and  disa- 
bilities, its  relative  strength  or  weakness,  may  be  best  appreciated 
by  comparing  it  with  the  normal  standard.  As  in  other  machines, 
marked  deformity  or  distortion  is  evident  at  a  glance,  even  though 
the  apparatus  is  not  in  use,  but  functional  ability  can  be  judged 
only  by  the  manner  in  which  active  work  is  performed. 

As  has  been  stated,  the  foot  is,  in  activity,  a  lever,  by  means 
of  which  the  weight  of  the  body  is  lifted  and  propelled.  If  it  is 
loosely  constructed  or  insufficiently  supported  by  the  ligaments, 
it  is  evident  that  it  cannot  be  properly  controlled  by  the  muscles. 
If,  on   the  other  hand,  the  muscular  power  is  insufficient,  it  is 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      661 

evident,    also,  that  the  weight  of  the  body  cannot  be  lifted  and 
properly  balanced  upon  it.     The  structure  of  the  foot  may  be 


Fig.  392. 


Fig.  393. 


Extensor  proprius  hallucis  of  right  side ;  out-    Extensor  longus  digitorum  of  right  side ;  out- 
line and  attachment  areas.    (Gerrish.)  line  and  attachment  areas.    (Gerrlsh. 

normal,  and  it.s  mu.sclcs  may  be  of  normal  strength,  yet  the  strain 
placed  upon  it  may  be  dis])roportionately  great.  The  strain  may 
be  overweight  of  body,  or  the  overwork  of  a  laborious  occupation, 


Fig.  394. 


Fig.  395. 


0 


0 


Flexor  longus  digitorum  of  right  side; 
outline  and  attachment  areas.  The  muscle 
is  represented  as  seen  from  in  front  through 
the  bones.    (Gerrish.) 


o 


Flexor  longus  hallucis  of  right  side ; 
outline  and  attachment  areas.  The 
muscle  is  represented  as  seen  from  the 
front  through  the  bones.    (Gerrish.) 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      663 

but  more  often  the  machine  is  overworked  simply  because  it  is 
subjected  to  mechanical  disadvantages  in  the  performance  of  its 
functions,  by  the  assumption  of  improper  attitudes. 

One  of  the  most  common  of  such  attitudes  is,  as  has  been 
mentioned,  that  of  turning  the  feet  outward  in  walking;  for  as 
the  fulcrum  is  displaced  outward,  the  strain  falls  through  the 
inner  and  weaker  side  of  the  foot.  As  a  consequence  of  the 
improper  attitude  there  is  usually,  to  a  greater  or  less  degree,  dis- 


FlG.  396. 


Fig.  397. 


An  attitude  that  simulates  the  flat-foot. 
(See  Fig.  397.) 


Fig.  397,  compared  with  Fig.  396, 
illustrates  the  voluntary  protection  of 
the  foot  from  overstrain. 


use  of  the  active  leverage  function  of  the  foot ;  the  active  lift  of 
the  calf  muscle  is  replaced  by  exaggerated  flexion  at  the  knee, 
the  foot  being  used  somewhat  as  if  it  were  a  movable  pedestal 
(Fig.  380). 

This  disuse  of  the  active  attitudes  may  be  unnecessary,  just  as 
the  outward  rotation  of  the  feet  with  which  it  is  associated  is  a 
habit,  a  habit  that  is  often  the  result  of  improper  teaching.  On 
the  other   liand,  the  habitual   assumption  of  the  passive  attitude 


664 


ORTHOPEDIC  SURGERY. 


may  be  induced  by  injury  or  disease  of  the  foot,  or  by  corns  or 
bunions,  or  by  improper  shoes. 


Fig.  398. 


Typical  "flat-foot"  of  moderate  degree, 
illustrating  the  component  elements  of  ab- 
duction and  depression  of  the  arch. 


Under  such  conditions  the  strain 
of  the  leverage  function  increases 
the  discomfort;  consequently  it 
is  discontinued.     It  must  not  be 
inferred  that  such  improper  at- 
titudes lead  directly  to  weakness 
and  discomfort,  for  in  most  in- 
stances an  ungraceful    carriage 
and  gait  are  the  only  ill  effects. 
The    improper   attitudes    must, 
however,  lessen  the  power  and 
resistance  of  the  foot,  and  they 
must    be    reckoned,    therefore, 
among  the  predisposing  causes 
of  disability  and  deformity. 
The  passive  attitude,  it  will 
•    be  remembered,  is  the  attitude  of 
rest,  in  which  the  ligaments  bear  the  greater  part  of  the  strain 
and  in  which  the  arches  of  the  foot  are  depressed  or  obliterated. 

The  Weak  Foot. 

Synonyms.     Splay-foot,  flat-foot. 

The  introductory  pages  lead  naturally  to  the  consideration  of 
the  most  important  of  the  acquired  disabilities  of  the  foot,  a  dis- 
ability whose  most  important  characteristic  in  the  mildest  and  in 
the  most  advanced  type  is  the  persistence  of  tJhe  passive  attitude, 
or  an  approximation  to  it,  in  place  of  active  motion  and  alterna- 
tion of  posture.  Disuse  of  function  is  followed  by  restriction  of 
motion,  particularly  in  the  range  of  adduction  and  plantar  flexion, 
and  finally  by  persistent  deformity,  a  deformity  which  is  simply 
an  exaggeration  of  the  normal  posture  assumed  when  the  foot 
supports  weight  (Fig.  396).  This  is  the  so-called  flat-foot  (Fig. 
398).  At  first  glance  it  may  seem  that  the  depression  of  the 
arch  is  the  most  noticeable  peculiarity  in  a  well-marked  case  of 
flat-foot,  and  that  the  popular  name  is,  therefore,  an  appropriate 
one,  but  on  closer  examination  it  will  be  evident  that  the  normal 
relation  between  the  leg  and  the  foot  is  changed.  This  change, 
which,  from  the  functional  standpoint,  is  of  far  greater  impor- 
tance than  the  depth  of  the  arch,  may  be  analyzed  as  follows  : 

Anatomy.  1.  The  leg  is  displaced  inward,  so  that  the  weight 
falls  upon  the  inner  side  of  the  foot.      2.  The  leg  is    rotated 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      665 

inward,  so  that  a  line  drawn  through  its  centre,  prolonged  from 
the  crest  of  the  tibia,  instead  of  falling  over  the  second  toe  now 
points  inside  the  great  toe,  or  even  over  the  centre  of  the  internal 
border  of  the  foot  (Figs.  398  and  401). 

It  has  been  stated  that  under  normal  conditions,  in  the  act  of 
passive  weight  bearing,  the  astragalus  rotates  downward  and 
inward  upon  the  os  calcis,  depressing  its  anterior  and  internal 
border  until  the  movement  is  checked  by  the  strong  ligaments 
connecting  the  bones,  the  calcaneonavicular,  the  deltoid,  and  the 
interosseus ;  in  other  words,  the  leg  has  a  tendency  to  slip  down- 
ward and  inward  from  off  the  foot.  In  the  weak  foot  this 
inclination  has  become  an  accomplished  fact,  for  the  normal 
movement  has  become  so  exaggerated  by  the  distention  of  the 
ligaments  and  by  the  weakness  of  the  supporting  muscles  that 
an  actual  subluxation  is  present.     The  astragalus  has  rotated  and 


FIG.  400. 


The  relation  of  the  astragalus  to  the 
OS  calcis. 


The  relation  of  the  astragalus  and  os 
calcis  in  flat-foot. 


slipped  far  to  the  inner  side  of  its  normal  position,  to  an  attitude 
of  exaggerated  rotation  and  plantar  flexion,  so  that  its  head  can 
be  plainly  felt  on  the  internal  border  of  the  foot.  The  anterior 
extremity  of  the  os  calcis  is  depressed  and  is  turned  slightly 
inward  and  its  internal  border  is  lowered  (Fig.  400). 

The  navicular  bone  has  been  depressed  with  the  head  of  the 
astragalus,  although  to  a  less  degree,  it  has  been  forced  further 
away  from  the  os  calcis,  and  the  entire  inner  border  of  the  foot 
is  lowered.  Thus  the  depression  of  the  arch  is  always  accom- 
panied and  preceded  by  a  bulging  inward  of  the  inner  side  of  the 
foot. 

The  typical  flat-foot  is,  as  it  were,  broken  in  the  centre  (Fig. 
31)8),  the  posterior  division  ha,ving  turned  inward  and  downward, 
while  the  forefoot  is  forced  downward  and  outward.  The  dislo- 
cation  may  ho  so  extreme  that  the  entire  sole  of  the  foot  rests 


666 


OR  THOPEDIC  S  UB  GEB  Y. 


upon  the  ground,  and  a  callus  even  may  be  found  at  the  point 
that  usually  represents  the  highest  point  of  the  arch,  which  now 
supports  the  greatest  burden. 

In  this  change  of  relation  between  the  bones  the  arched  part 
of  the  foot  or  waist  appears  much  broader  than  normal,  even 
broader  than  the  front  of  the  foot ;  the  heel  projects,  the  external 
malleolus  is  depressed  and  carried  forward  by  the  rotation  of  the 

leg,  and  is  much  less  prominent 
Fig.  401.  than    normal  ;     the    internal 

malleolus  is  more  prominent, 
and  with  the  astragalus  it  over- 
hangs the  bearing  surface  of 
the  sole.  The  entire  mechan- 
ism is  twisted  and  out  of  gear  ; 
its  motion  is,  therefore,  very 
much  restricted.  It  is  mani- 
festly impossible  for  the  patient 
to  adduct  the  forefoot  —  that 
is,  to  turn  it  inward  about  the 
head  of  the  displaced  astrag- 
alus. Plantar  flexion  is  also 
much  limited,  because  of  the 
persistent  adduction  and  plan- 
tar flexion  of  the  astragalus. 
Dorsal  flexion,  on  the  other 
hand,  although  it  is  actually 
restricted,  may  appear  to  be 
abnormally  free,  because  the 
forefoot  is  abducted  and 
slightly  dorsiflexed  upon  the 
head  of  the  astragalus  (Fig. 
398). 

The  disability  and  its  accom- 
panying deformity  are  found 
in  every  grade  of  severity.  Pain  begins  when,  the  support  of  the 
muscles  being  insufficient,  the  ligaments  begin  to  give  way  under 
strain,  allowing  the  bones  to  occupy  an  abnormal  relation  to  one 
another.  It  is  evident,  therefore,  that  the  individual  in  whose 
foot  the  arch  is  well  formed  and  whose  ligaments  are  firm,  will 
suffer  from  the  symptoms  of  strain  long  before  the  arch  has  been 
depressed  or  deformity  has  become  apparent ;  also,  that  the  lateral 
inward  bulging,  characteristic  of  advancing  deformity,  must  be 


Weak  feet,  showing  the  inward  rotation  of 
the  legs  when  the  ahducted  feet  are  placed  side 
by  side. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      667 


Fia.  402. 


very  great  before  the  arch  is  completely  flattened.  In  this  type 
the  prominent  deformity  is  lateral  displacement  (valgus).  On 
the  other  hand,  if  the  individual  has  inherited  a  low  arch,  as  is 
characteristic  of  certain  races,  or  if,  as  the  result  of  weakness  in 
early  life,  the  arch  has  been  depressed  or  has  never  formed, 
accommodative  changes  in  the  bones  will  have  taken  place  during 
growth,  so  that  the  flat-foot  of  this  type  will  not  be  attended  with 
as  much  change  in  its  relation  to  the  leg,  and,  therefore,  disturb- 
ance of  function,  as  in  the  typical  case  that  has  been  described. 
This  latter  class  of  cases  exemplifies  the  popular  type  of  flat-foot 
that  may  exist  without  pain  or  disability,  and  in  which  the  most 
noticeable  peculiarity  is  the  obliteration  of  the  arch  (planus). 
(Contrast  Figs.  402  and  404.) 

In  certain  instances  abnormal  laxity  of  ligaments  allows 
deformity  of  the  valgus  type  when  weight  is  borne,  yet  the  foot, 
controlled  by  efficient  muscles, 
may  be  apparently  normal  in 
functional  ability,  while  in  other 
cases  in  which  the  ligaments 
are  normal  and  yet  are  subjected 
by  insufficient  muscular  protec- 
tion to  overstrain,  disability 
and  pain  may  precede  notice- 
able deformity. 

It  is  evident  that  the  lower- 
ing of  the  arch  is  of  secondary 
importance  in  the  deformity, 
andthat  the  popular  significance 
of  painful  flat-foot,  as  an  in- 
herited and  irremediable  weak- 
ness, is  most  misleading.  Yet 
it  seems  to  have  governed  the 
treatment  of  the  disability  until 
very  recently.  On  the  one 
hand,  the  early  cases  were  over- 
looked because  the  foot  was  not  flat,  while  those  in  which  the 
deformity  was  more  advanced  were  simply  neglected  or  were 
treated  by  simple  supports  beneath  the  arch  or  by  operation, 
without  regard  to  the  loss  of  function,  and,  therefore,  without 
liope  of  ultimate  cure. 

As   has   been   stated,  there  is  one  feature   common    to  every 
grade  of  the  so-called  flat-foot :  the  foot  regarded  as  a  machine  is 


Weak  feet,  arch  not  depressed. 


668  ORTHOPEDIC  SURGERY. 

weak  as  compared  to  the  normal  standard — weak  because  of  the 
persistence  of  the  attitude  of  rest  and  relaxation,  as  contrasted 
with  that  of  activity  and  strength,  and  weak  because  the  proper 
relation  between  the  power  and  the  fulcrum  is  changed.  Even 
the  inherited  flat-foot  or  the  flat-foot  which  has  never  caused 
symptoms  is  weak  in  the  sense  that,  in  use,  it  lacks  the  spring 
and  elasticity  characteristic  of  the  perfect  machine.  The  term 
weak  foot  may  be  used,  then,  to  indicate  all  types  of  the  disa- 
bility. 

In  one  weak  foot  the  arch  has  disappeared  (Fig.  398)  ;  in 
another  weak  foot  the  arch  is  of  normal  depth,  but  the  foot  is 
abducted  or  pronated  in  its  relation  to  the  leg  (Fig.  397).  In 
one  case  the  deformity  appears  only  under  weight:  in  another 
the  foot  is  held  rigidly  in  the  deformed  position  by  muscular 
spasm.  In  one  instance  there  may  be  great  deformity  without 
pain;  and  in  another  disabling  weakness  and  pain  without 
noticeable  deformity.  In  one  case  the  foot  is  unable  to  perform 
its  functions  because  of  its  inherent  weakness ;  in  another  the 
disability  may  be  due  simply  to  the  improper  use  of  a  normal 
structure. 

Pathology.  Supposing  the  foot  to  have  been  normal  before  it 
began  to  break  down,  it  is  evident  that  persistent  deformity  could 
not  have  been  acquired  without  marked  changes  in  its  internal 
structure.  In  a  general  way  these  changes  have  been  indicated 
already.  The  ligaments  on  the  internal  aspect  of  the  foot  and  of 
the  ankle-joint  are  weak  and  distended ;  the  unused  portions  of  the 
articular  surfaces  of  the  joints  may  be  denuded  of  cartilage,  while 
new  facets  may  have  formed  to  accommodate  the  changed  rela- 
tions of  the  bones.  For  example,  the  external  malleolus  may  be 
in  direct  contact  with  the  os  calcis;  evidences  of  injury  and  of 
abnormal  pressure  may  be  found  in  the  thickened  periosteum, 
in  formation  of  osteophytes,  while  the  internal  structure  of  the 
bones  has  been  changed  in  adaptation  to  the  new  conditions.  The 
muscles  which  are  no  longer  used  in  the  leverage  function,  the 
plantar  flexors  and  adductors,  have  become  atrophied,  a  change 
that  is  made  evident  by  the  shrunken  calf.  The  muscles  on  the 
inner  border  of  the  foot  have  been  overstretched,  while  those  on 
the  upper  and  outer  part  have  become  shortened  and  contracted. 
Such  a  foot  represents  an  extreme,  it  may  be  an  irremediable 
degree  of  deformity  ;  but  in  by  far  the  greater  proportion  of  the 
cases  the  pathological  changes  have  not  advanced  to  a  stage  that 
interferes  with  successful  treatment. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      669 

Etiology.  In  all  cases  the  actual  symptoms  of  pain  and  dis- 
ability are  due  to  a  disproportion  between  the  burden  or  strain 
and  the  ability  of  the  machine  to  perform  it. 

This  theory  accounts  for  the  fact  that  the  weak  foot,  although 
very  common  in  childhood,  does  not,  as  a  rule,  cause  troublesome 
symptoms  until  adolescence,  when  the  weight  and  strain  put  upon 
it  are  increased.  It  explains  why  the  foot,  which  may  be  fairly 
normal  in  structure,  breaks  down  often  in  later  adolescence  or 
early  adult  life  when  the  continuous  strain  of  regular  occupation 
is  undertaken.  It  is  evident,  also,  that  an  occupation  that 
induces  a  persistence  of  the  passive  attitude,  that  of  waiters, 
cooks,  and  bartenders,  for  example,  exposes  the  feet  to  greater 
strain  than  one  which  encourages  alternation  of  postures.  And 
that  the  symptoms  are  likely  to  be  more  severe  and  the  deformity 
to  be  greater  among  those  who  are  obliged  to  labor  than  among 
those  who  are  not.  Overwork  or  strain,  of  occupation  or  other- 
wise, may  be  temporarily  disproportionate  because  of  general 
weakness,  as,  for  example,  during  pregnancy  or  after  recovery 
from  exhausting  disease ;  or  because  of  local  injury  or  disease  of 
the  foot  itself  which  weakens  it  directly  or  induces  improper 
attitudes.  On  this  theory  one  may  very  easily  explain  what  has 
proved  such  a  stumbling-block  for  students,  viz.,  that  there  is  no 
constant  relation  between  the  degree  of  deformity  and  the  severity 
of  the  symptoms,  for,  although  all  flat-feet  are  mechanically  weak, 
yet  all  weak  feet  are  not  necessarily  painful  feet.  Pain  is  not 
caused  because  the  foot  is  flat ;  it  is  a  symptom  of  progressive 
deformity  and  of  strain  and  injury  to  the  joints.  The  progress 
of  the  deformity  may  be  temporarily  or  permanently  checked  at 
any  stage,  either  by  removal  of  the  exciting  cause  or  because 
of  the  resistance  of  the  tissues ;  then  the  pain  intermits  or  ceases. 

This  conception  of  the  foot  as  a  mechanism,  of  which  grades 
of  efficiency  may  be  recognized,  has  a  great  advantage,  since  it 
enables  one  to  perceive  wherein  a  foot  is  weak,  even  though  the 
weakness  causes  no  symptoms  whatever,  and  thus  to  prevent  dis- 
comfort and  deformity  by  a  recognition  of  its  predisposing  causes. 
Finally  from  this  standpoint  one  cannot  fail  to  appreciate  the 
importance  of  improper  shoes  in  the  etiology  of  this  and  of  all 
forms  of  acquired  weakness  of  the  feet,  a  subject  to  which 
special  attention   will   be  called  in  another  section. 

Statistics.  A  brief  analysis  of  1000  cases  of  so-called  flat-foot 
treatofl  at  the  Hospital  for  Kuptured  and  Crippled  will  represent 
fairly  the  points  of  general  interest  in  this  class  of  cases  : 


670  OBTHOPEDIG  SURGERY. 

The  Age  and  Sex  of  the  Patients. 

Age.  Males.  Females.    Total. 

Ten  years  or  less 68  30  98 

Ten  to  fifteen 112  87  199 

Fifteen  to  twenty 144  83  227 

Twenty  to  twenty-five 94  53  147 

Twenty-flve  to  thirty 68  41  109 

More  than  thirty 132  88  220 

618         382         1000 
Foot  affected:  right,  133;  left,  138;  both,  729. 

In  58  cases  the  cause  of  the  disability  appeared  to  be  injury, 
and  in  65  instances  it  was,  apparently,  due  to  rheumatism  or  to 
rheumatoid  arthritis.  The  symptoms  usually  appear  first  in  one 
foot,  and,  as  a  rule,  they  are  at  all  times  more  marked  on  one 
side.  Of  569  instances,  in  which  the  duration  of  symptoms  was 
recorded,  it  was  six  months  or  less  in  409. 

The  age  of  the  patients  is  of  interest  as  bearing  on  the  question 
of  prognosis  ;  426  were  between  ten  and  twenty  years  of  age,  and 
780  were  less  than  thirty. 

Hospital  statistics  cannot  adequately  represent  the  subject,  for, 
as  a  rule,  it  is  because  of  disability  and  pain  that  these  patients 
apply  for  treatment.  In  the  larger  proportion  of  the  cases 
recorded  muscular  spasm  and  rigidity  were  present,  in  234 
instances  to  such  a  degree  that  forcible  overcorrection  was 
advised — an  operation  rarely  necessary  in  private  practice. 

It  is  in  childhood  that  the  prevention  of  subsequent  weakness 
and  deformity  is  of  the  first  importance,  yet  but  98  children  of 
ten  years  of  age  or  less  are  recorded,  and  many  of  these  were 
brought,  not  for  weakness  or  deformity,  but  for  treatment  of  the 
symptomatic  in-toeing. 

Symptoms.  As  has  been  stated,  the  symptoms  of  the  weak 
foot,  although  similar  in  type,  vary  in  severity  according  to  the 
local  condition  and  the  disturbance  of  function,  the  work  to  be 
performed,  and  the  susceptibility  of  the  individual.  The  earliest 
symptom  is  usually  a  sensation  of  weakness ;  the  patient  begins 
to  recognize  as  familiar  a  feeling  of  discomfort,  of  tire  and  strain 
about  the  inner  side  of  the  foot  and  ankle ;  sometimes  after  long 
standing  a  dull  ache  in  the  calf  of  the  leg  or  pain  at  the  knee, 
hip,  or  in  the  lumbar  region,  symptoms  more  common  in  women 
than  in  men ;  or  after  overexertion  a  momentary  sharp  pain  radi- 
ating from  the  point  of  weakness  ;  thus  the  patient  often  dates  the 
history  of  his  trouble  from  a  long  walk  or  other  form  of  over- 
work. After  a  time  the  patient  may  become  aware  that  he  is  accom- 
modating his  habits  to  his  feet ;  he  rides  when  he  once  walked  ;  he 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     671 

sits  when  he  once  stood  ;  he  no  longer  runs  up  or  down  stairs  or 
jumps  off  the  street-car.  His  feet  have  lost  their  spring,  as  he 
expresses  it,  which  means  that  the  foot  is  no  longer  supported  and 
controlled  by  muscular  activity  and  is  no  longer  used  as  a  lever. 
Not  infrequently  early  symptoms  are  pain  and  tenderness  at  the 
centre  of  the  heel,  explained  in  part  by  the  jarring  heel  walk  which 
is  always  assumed  when  the  foot  is  weak,  and  in  part  by  the  strain 
upon  the  attachments  of  the  deep  plantar  ligaments.  The  patient 
may  complain  that  he  cannot  buy  comfortable  shoes  ;  the  reason 
is  that  the  weak  foot  under  use  is  changed  in  shape,  so  that  the 
shoe  that  was  comfortable  in  the  morning  compresses  the  foot 
painfully  at  night ;  thus  increasing  discomfort  from  corns,  bunions, 
painful  great  toe-joints,  and  deformities  of  the  toes  is  experienced. 
Coldness  and  numbness,  congestion  and  increased  perspiration, 
caused  by  the  impaired  circulation  and  weakness,  are  common 
symptoms  in  this  class  of  cases.  Actual  pain  is,  as  a  rule,  felt 
only  when  the  foot  is  in  use ;  it  ceases  under  temporary  rest  or 
relief  from  disproportionate  work,  and  it  is  this  remittance  of 
symptoms,  together  with  the  fact  that  the  discomfort  is  usually 
more  marked  in  damp  weather,  that  leads  so  often  to  the  mistaken 
diagnosis  of  rheumatism.  The  foot  is  weak  and  vulnerable  ;  the 
patient  recognizes  the  fact  that  he  has  what  he  speaks  of  as  a 
weak  ankle,  or  sprain,  or  gout,  or  rheumatism,  but  if  he  has 
accommodated  himself  to  the  weakness  but  little  discomfort  is 
experienced.  In  many  instances  such  relief  or  accommodation  is 
impossible,  and  it  is,  therefore,  among  the  working  class  that  one 
oftener  sees  the  frank  and  rapid  development  of  the  disability 
and  deformity.  The  range  of  motion  becomes  more  and  more 
restricted  ;  the  habitual  attitude,  at  first  exaggerated  to  deformity 
only  under  the  influence  of  the  weight  of  the  body,  remains  as  a 
permanent  displacement  of  the  bones.  The  weak  and  dislocated 
foot  is  subjected  to  constant  injury,  to  what  may  be  likened  to  a 
succession  of  slight  sprains,  so  that  local  congestion,  tenderness, 
and  swelling  may  appear  together  with  muscular  spasm,  rigidity, 
and  pain  on  passive  motion.  Because  of  this  rigidity  of  the  foot, 
which  has  lost  the  power  to  accommodate  itself  to  inequalities  of 
the  surface,  the  patient  dreads  to  cross  a  rough  pavement,  for 
every  misstep  is  a  source  of  pain.  Another  symptom,  the  dis- 
comfort felt  in  changing  from  a  position  of  rest  to  activity, 
which  is  usually  present  in  slight  degree  at  every  stage,  now 
becomes  more  prominent.  Tlie  patient,  after  sitting  or  on  rising 
in   the   morning,  is   unable   to  walk,  but   staggers  or  limps  for 


672  OB  TH  OPE  Die  SUBGEB  Y. 

several  minutes,  a  symptom  explained  by  the  fact  that  when  the 
foot  is  at  rest  there  is  a  partial  reposition  of  the  displaced  bones, 
which  must  a^ain  be  forced  into  the  deformed  posture  that  has 
become  habitual.  The  local  tenderness  and  muscular  spasm  are 
increased  by  use,  so  that  the  patient  may  have  difficulty  in 
removing  the  shoe  at  night,  and  the  symptoms  relieved  by  the 
rest  of  Sunday  become  progressively  worse  during  the  week. 
The  pain  and  discomfort  are  more  general  in  character,  and  are 
often  referred  to  the  dorsum  of  the  foot,  representing  muscular 
rigidity  and  tension,  and  to  the  ankle  where  the  external  malle- 
olus is  grinding  out  a  facet  in  the  projecting  os  calcis.  The 
patient  may  now  complain  of  discomfort  in  the  feet  and  cramps 
in  the  legs,  even  when  in  bed,  and  the  appearance  of  weakness, 
awkwardness,  and  depression  of  spirits  may  be  so  noticeable 
that  the  case  is  sometimes  mistaken  for  serious  disease  of  the 
nervous  system. 

The  appearance  of  such  a  foot  has  already  been  described,  and 
the  effect  of  the  deformity  on  its  functions  should  be  evident. 
The  gait  is  slouchy  and  cloddy,  what  has  been  spoken  of  as  the 
pedestal  walk ;  the  feet  are  simply  pushed  by  one  another,  in 
the  attitude  of  eversion,  the  knees  are  slightly  flexed  and  the 
weight  is  borne  entirely  upon  the  posterior  segment  of  the  foot. 
The  muscles  have  atrophied,  the  foot  is  cold  and  congested  from 
its  continued  inactivity,  and  it  is  usually  bathed  in  perspiration. 
A  certain  range  of  motion  remains  at  the  ankle-joint,  but  adduc- 
tion is  absolutely  restricted  by  the  shortened  and  spasmodically 
contracted  muscles  on  the  outer  and  upper  surface.  This  type 
represents,  of  course,  only  the  severe  variety  that  is  more  likely 
to  be  seen  in  hospital  than  in  private  practice  ;  and  it  would 
seem,  were  it  not  for  the  evidence  to  the  contrary  which  the 
histories  of  the  patient  present,  that  the  nature  of  the  trouble 
must  be  recognized  at  a  glance.  But  in  the  milder  and  earlier 
cases  the  diagnosis  is  not  always  so  easily  made. 

Diagnosis.  In  all  cases  of  suspected  weakness  of  the  foot  a 
thorough  and  orderly  examination  should  be  made,  not  only  of 
its  appearance,  but  also  of  its  functional  ability  and  of  the  manner 
in  which  it  is  used.  Such  an  examination  is  not  merely  for  the 
purpose  of  diagnosis,  which  is  usually  apparent,  but  in  order  that 
the  amount  and  character  of  the  temporary  or  permanent  changes 
in  structure  and  function  may  be  properly  estimated. 

Attitudes.  One  begins  the  examination  by  noting  the  manner 
of  standing  and  walking.     The  heel  walk,  the  exaggerated  turn- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      673 

ing  out  of  the  feet,  the  slouchy  gait  in  which  the  leg  is  never 
completely  extended,  in  which  the  power  of  the  calf  muscle  is 
not  applied,  and  in  which  the  essential  postures  of  the  foot  are 
disused,  are  all  elements  of  weakness  that  should  be  corrected 
whether  they  cause  symptoms  or  not. 

Distribution  of  Weight  and  Strain.  The  distribution  of  the 
weight  of  the  body  and  the  habitual  use  of  the  foot  are  often 
made  evident  by  examining  the  worn  shoe.  If  it  is  bulged  inward 
at  the  arch  or  worn  away  on  the  inner  side  of  the  sole  it  shows 
weakness  (Fig.  405).  The  same  observations  are  then  made  on 
the  bare  feet,  particular  attention  being  paid  to  tlie  line  of  strain 
or  leverage  ;  thus  a  line  drawn  down  to  the  crest  of  the  tibia  from 
the  centre  of  the  patella,  continued  over  the  foot,  should  meet  the 
interval  between  the  second  and  third  toes ;  if  it  falls  over  or 
inside  the  great  toe,  it  shows  that  the  foot  is  working  at  a 
disadvantage  (Fig.  401). 

Contour.  The  contour  of  the  foot  should  then  be  examined ; 
its  internal  border  should  curve  slightly  outward,  so  that  if  the 
feet  are  placed  side  by  side  with  the  toes  and  heels  in  apposition 
a  slight  interval  remains  between  them ;  if  this  slight  concavity 
is  replaced  by  a  noticeable  convexity  when  weight  is  borne  the 
foot  is  weak  (Fig.  402).  This  change  in  contour  is  the  earliest 
and  sometimes  the  only  evidence  of  deformity.  The  arch  of  the 
foot,  properly  protected  by  the  muscles  and  by  a  proper  attitude, 
sinks  but  slightly  under  weight ;  there  is  a  slight  elasticity  only, 
as  the  strain  is  thrown  more  to  the  inner  side  of  the  median  line, 
and  if  the  depression  is  marked  it  shows  weakness. 

Bearing  Surface.  The  exact  amount  of  bearing  surface  may  be 
shown  by  an  imprint  upon  carbon  paper  or  by  smearing  the  sole 
with  vaseline;  then,  as  the  patient  stands  upon  a  sheet  of  white 
paper,  the  outline  of  the  foot  should  be  traced  so  that  the  relative 
size  of  the  imprint  to  that  of  the  foot  may  be  shown  and  compared 
with  the  normal  standard. 

Another  method  is  that  suggested  by  Lovett.  The  patient 
stands  upon  a  square  of  plate  glass  fixed  in  a  table,  so  that  by 
means  of  a  mirror  beneath  the  bearing  surface  may  be  examined 
under  different  degrees  of  pressure  and  in  different  attitudes 
(Fig.  407). 

The  Range  of  Motion.  The  balance  of  the  foot,  as  shown  by 
the  range  of  motion,  is  next  to  be  tested,  for  its  limitation  is  one 
of  tl)e  earliest  signs  of  improper  attitudes  and  of  weakness.  This 
range  of  motion  varies  somewhat  within  normal  limits  ;    it  is 

43 


674  OR  THOPEDIC  S  UB  GEB  Y. 

usually  greater  in  childhood  than  in  adult  life,  greater  in  the 
slender  than  in  the  massive  foot,  and  greater  in  the  foot  used 
properly  than  in  one  that  is  not.  The  first  test  is  applied  to 
simple  dorsal  and  plantar  flexion ;  the  leg  must  be  fully  extended 
at  the  knee ;  the  line  of  strain  must  be  in  its  normal  relation,  so 
that  the  foot  may  be  neither  adducted  nor  abducted,  and  the 
observation  must  be  made  on  its  outer  border. 

In  this  position  the  patient  should  be  able  to  flex  the  foot  from 
ten  to  twenty  degrees  less  than  the  right  angle,  and  to  extend  it 
from  forty  to  fifty  degrees  beyond  the  right  angle,  the  range  of 
motion  being  from  fifty  to  sixty  degrees  (Figs.  381  and  382). 

By  far  the  most  important  test  is  that  of  the  power  of  adduc- 
tion or  inversion  of  the  foot,  the  test  of  the  mediotarsal  and 
subastragaloid  joints,  a  motion  in  which  the  os  calcis  is  drawn 
forward  and  inward  under  the  astragalus,  while  the  forefoot  is 
flexed  about  its  head.  With  the  leg  extended  and  the  patella  in 
the  median  line  the  foot  is  turned  inward  as  far  as  possible ;  the 
elevation  of  its  inner  border  or  supination  and  the  turning  in  of 
the  heel  are  well  illustrated  in  Fig.  383  ;  the  actual  range  of 
adduction  is  somewhat  difficult  to  measure,  but  it  is  about  thirty 
degrees.  Even  the  mild  and  early  cases  of  weak  foot  usually 
show  some  limitation  of  this  most  important  motion,  and  in  many 
instances  it  is  completely  lost,  the  patient  turning  the  entire  leg 
in  the  effort  to  adduct  the  foot.  The  less  important  motion  of 
abduction  may  be  tested  also  (Fig.  384)  ;  its  range  is  about  half 
that  of  adduction,  so,  also,  the  range  of  supination  or  inversion  of 
the  sole  is  nearly  twice  as  great  as  that  of  pronation  or  eversion 
of  the  sole.  In  other  words,  the  internal  border  of  the  foot  can 
be  raised  twice  as  far  from  the  floor  as  can  the  external  border. 
The  range  of  passive  motion  is  then  tested  by  pushing  the  foot  in 
all  directions.  The  range  of  dorsal  flexion  is  from  five  to  ten 
degrees  beyond  that  of  voluntary  motion,  while  passive  extension, 
so  far  as  it  applies  to  the  ankle-joint,  is  about  the  same  as  the 
voluntary,  although  the  forefoot  may  be  still  farther  bent  down- 
ward at  the  mediotarsal  joint.  The  limit  of  passive  adduction  is 
considerably  beyond  that  of  voluntary  inversion.^ 

Passive  motion  serves  several  purposes ;  contrasted  with  the 

1  As  adduction  and  supination  and  abduction  and  pronation  are  always  combined,  one 
term  is  used  to  signify  tbe  movement  inward  or  outward  ;  thus,  supination  means  adduc- 
tion ;  abduction  implies  pronation.  A  fixed  attitude  of  adduction  and  supination  is  called 
varus ;  a  fixed  attitude  of  abduction  and  pronation  is  called  valgus.  Varus  and  valgus  sig- 
nify, therefore,  deformity.  Thus  the  term  valgus,  although  it  may  be  properly  applied  to 
designate  the  deformity  of  weak  foot,  is  usually  reserved  lor  the  more  extreme  distortion  of 
talipes.    (See  Figs.  383  and  384.) 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     675 

range  of  voluntary  motion  it  shows  the  habitual  use  of  the  foot, 
since  the  motion  least  used  is  most  limited.  It  also  makes  evi- 
dent the  slight  restriction  of  motion  and  the  presence  of  local 
tenderness,  which,  even  in  early  cases,  are  usually  present. 
Thus,  if  pressure  is  made  just  in  front  of  and  below  the  internal 
malleolus,  at  the  astragalonavicular  junction,  and  if  at  the  same 
time  the  foot  is  forcibly  adducted,  the  patient  will  complain  of 
pain  at  the  point  of  pressure  and  of  a  feeling  of  constriction  and 
tension  about  the  dorsum  of  the  foot  before  the  normal  limit  of 
motion  is  reached.  When  the  foot  is  dorsiilexed  the  plantar 
fascia  is  put  upon  the  stretch,  and  its  condition  may  be  noted, 
for  a  contracted  and  sensitive  plantar  fascia  may  cause  sufficient 
discomfort  to  induce  improper  attitudes  and  thus  it  may  predis- 
pose to  further  disability. 

Varieties.  This  mode  of  examination  will  demonstrate  the 
disability,  and  the  secondary  changes  in  the  mechanism,  which 
must  be  overcome  before  a  cure  can  be  accomplished.  By  it  one 
will  learn  to  recognize  several  grades  of  weak  foot : 

1.  The  normal  foot  improperly  used,  as  shown  by  the  manner 
of  standing  and  walking  (Fig.  375). 

2.  The  foot,  which  because  of  laxity  of  ligaments  or  insufficient 
muscular  support,  is  forced  by  the  weight  of  the  body  into  an 
attitude  of  deformity  ;  that  is,  in  which  the  foot  under  weight 
falls  into  an  abnormal  attitude  of  abduction  in  its  relation  to  the 
leg,  as  evidenced  by  the  inward  projection  of  its  inner  border  and 
by  the  overhanging  internal  malleolus,  showing  that  the  leg  has 
been  displaced  inward  on  the  foot.  As  a  rule,  there  is  sufficient 
laxity  of  ligaments  to  allow  a  depression  of  the  arch,  as  shown  by 
the  imprint,  but  in  other  instances,  although  the  arch  seems  lower 
because  of  the  characteristic  attitude  of  pronation,  in  which  the 
leg,  as  it  were,  overhangs  the  foot,  yet  the  imprint  shows  that 
there  is  no  increase  in  the  area  of  bearing  surface.  Indeed,  if  the 
aversion  is  sufficient  to  raise  the  outer  border  of  the  foot,  this  may 
be  even  smaller  than  normal ;  thus,  an  individual  may  suffer  from 
so-called  flat-foot  whose  arch  is  actually  exaggerated  (Fig.  397). 

3.  The  weak  foot,  which  sliows  typical  deformity  under  use 
and  in  which  the  range  of  voluntary  motion  is  somewhat  limited, 
particularly  in  tlie  direction  of  plantar  flexion  and  adduction. 
Forced  motion  causes  discomfort  and  pain,  indicating  a  certain 
permanent  accommodative  change  in  structure,  whicli  is  not 
apparent  wlien  the  foot  is  not  in  use  (Fig.  396). 

4.  The  foot  which  j)resents  typical  and  permanent  deformity, 


676  ORTHOPEDIC  S UB OEB  Y. 

whether  it  is  in  use  or  not,  and  in  which  the  range  of  both  volun- 
tary and  passive  motion  is  much  restricted.  In  all  of  these  varieties 
the  improper  functional  use  of  the  foot,  particularly  the  loss  of 
active  leverage,  is  very  evident  when  the  patient  walks  (Fig.  405). 

Limitation  of  Motion  and  Muscular  Spasm.  Limitation  of  motion 
is  caused  by  the  accommodative  changes  in  structure  to  the 
habitual  postures  or  to  the  deformity.  These  are  first  evident  in 
the  muscles  and  ligaments,  and,  finally,  in  the  articular  surfaces 
of  the  bones.  Added  to  this  underlying  limitation  of  motion 
there  is  usually  a  certain  degree  of  muscular  spasm,  which  varies 
in  degree  with  the  local  congestion,  irritation,  and  inflammation 
of  the  joints  and  tissues.  In  the  quiescent  flat-foot  it  ma)'^  be 
absent,  but  on  renewed  injury  or  overwork  of  the  weak  structure 
it  again  appears.  It  depends  also  upon  the  irritable  condition  of 
the  overworked  and  contracted  abductor  muscles,  practically  the 
only  group  which  retains  functional  power ;  thus  the  spasm,  as 
has  been  stated  in  describing  the  severe  and  painful  type  of  weak 
foot,  is  greater  after  the  day's  use  and  relaxes  somewhat  during  the 
night.  The  degree  of  muscular  spasm  and  rigidity  corresponds 
with  the  intensity  of  the  symptoms,  but  by  no  means  with  the 
depression  of  the  arch  or  with  the  duration  of  the  deformity. 

Extreme  Types  ofWeak  Foot.  1.  Persistent  Abduction.  In 
one  type  of  deformity  the  foot  is  twisted  outward  and  upward. 
It  may  be  everted  to  such  an  extent  that  practically  the  weight 
is  borne  upon  the  heel  and  the  ball  of  the  great  toe.  In  such 
instances  the  astragalus,  although  rotated  inward  upon  the 
pronated  os  calcis,  is,  of  course,  not  plantar  flexed  nor  is  the 
anterior  extremity  of  the  os  calcis  depressed.  The  entire  foot  is 
simply  held  in  an  attitude  of  extreme  abduction  and  dorsal  flexion 
by  the  spasm  and  contraction  of  the  flexors  and  abductors,  so  that 
the  leg  must  be  bent  at  the  knee  and  inclined  forward  to  bring 
the  sole  to  the  ground.  Such  extreme  cases  are  uncommon. 
They  are  often  the  direct  result  of  injury,  so-called  chronic  sprain. 
Less  extreme  examples  of  this  class  are  very  common.  The  foot 
is  simply  turned  to  one  side  (valgus)  and  the  arch  appears  to  be 
depressed  because  of  the  attitude,  whereas  it  may  be  in  reality 
exaggerated  in  depth. 

2.  Pes  Planus.  As  has  been  stated  already,  and  as  is  well- 
known,  there  is  a  type  of  painless  flat-foot  sometimes  called  pes 
planus,  in  which  the  flatness  of  the  foot  is  more  noticeable  than 
the  other  components  of  the  deformity  that  have  been  described. 
This  is  probably  the  result  of  inherited  laxity  of  ligaments  or  of 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      677 

rhachitis  or  other  form  of  acquired  weakness  in  early  life,  so  that 
a  normal  arch  was  never  present.  Such  a  foot  controlled  by 
normal  muscles  may  be  strong  and  efficient,  but  it  is,  nevertheless, 
deformed,  and  it  is  doubtful  if  its  possessor  ever  could  attain  the 
grace  and  elasticity  of  gait  possible  under  normal  conditions.  It 
is  said,  also,  that  a  low  arch  is  normal  in  certain  races,  for 
example,  the  negro,  but  it  is  certain  that  the  American  negro  is 
not  exempt  from  the  pain  and  disability  incidental  to  the  broken- 
down  foot,  whether  his  arch  was  originally  low  or  not. 

It  is  evident,  of  course,  that  the  breaking  down  of  a  properly 
shaped  foot,  provided  with  normal  ligaments,  will  be  attended 

Fig.  403. 


Weak  feet  and  slight  knock-knees. 


by  greater  pain  and  greater  disability  than  of  one  in  which  the 
arch  was  originally  low  and  of  which  the  ligaments  were  weak, 
because  it  is  during  the  progression  of  the  deformity  and  particu- 
larly in  its  early  stages  that  such  symptoms  are  most  prominent. 
When  the  bones  of  the  arch  rest  upon  tlie  ground  or  when  final 
stability  has  become  assured,  pain  may  cease,  and  permanent 
accommodation  to  the  now  conditions  may  increase  tlie  ability  of 
the  deformed  member.  Such  an  outcome  might  be  quickly 
accomplished  in  the  foot  originally  flat,  while  in  the  other  instance 


678  OB  THOPEDIC  S  UB  GEB  Y. 

the  symptoms,  although  remitting  from  time  to  time,  might  con- 
tinue during  the  life  of  the  sufferer. 

The  abducted  foot,  in  which  there  is  no  depression  of  the  arch, 
and  the  simple  flat-foot,  in  which  the  element  of  abduction  is  less 
prominent,  represent  the  two  extremes  of  weak  foot.  In  the 
majority  of  cases  the  abduction  is  combined  with  a  certain  laxity 
of  the  supports  of  the  longitudinal  arch  as  well. 

One  may  recognize,  then,  in  the  weak  foot  three  types  of 
deformity : 

1.  Valgus,  or  abduction. 

2.  Valgoplanus,  or  abduction  and  depression. 

3.  Planus,  or  depression. 

This  distinction  is  of  some  importance  from  the  standpoint  of 
prognosis  at  least  in  the  adolescent  and  adult  cases,  as  the  pros- 
pect of  anatomical  cure  corresponds  with  the  order  of  classification. 

Weak  Foot  in  Childhood. 

There  can  be  no  doubt  that  in  many  instances  the  origin  of  the 
weak  foot  may'  be  traced  to  early  childhood.  Certainly,  deform- 
ities and  improper  attitudes  are  very  common  at  this  period,  and 
it  is  much  more  likely  that  they  are  ingrown  than  outgrown. 
Actual  pain  from  the  weak  foot  is  rare  at  this  age.  The  child 
may  complain  of  fatigue  and  may  be  weak  and  awkward,  but  it 
is  usually  because  of  the  very  evident  deformity  rather  than 
because  of  symptoms  that  advice  is  asked.  In  these  cases,  as  in 
every  case,  the  habitual  attitudes  and  use  of  the  feet  are  of  the 
first  importance. 

Out-toeing  and  In-toeing  as  Symptoms  of  the  Weak  Foot  in 
Childhood.  One  of  the  most  frequent  of  the  improper  postures 
is  that  of  exaggerated  outward  rotation  of  the  feet,  which  is  not 
only  an  ungraceful  attitude,  but  a  direct  cause  of  weakness  as  well. 
The  opposite  attitude  of  inward  rotation,  the  so-called  ''  pigeon- 
toed  "  walk,  is  most  offensive  to  relatives  and  friends,  and  it  is 
for  correction  of  the  attitude  that  the  child  may  be  brought  for 
treatment.  The  attitude  is,  in  many  instances,  a  sign  of  the  weak 
foot,  for  on  examination  the  bulging  on  the  inner  side,  the  inward 
rotation  of  the  leg  in  its  relation  to  the  foot,  and  the  depressed 
arch  show  very  plainly  that  it  is  the  foot  and  not  the  attitude 
that  requires  treatment;  in  fact,  the  attitude  is,  in  this  class  of 
cases,  really  a  safeguard  against  increasing  deformity,  and  it  will 
correct  itself  when  its  cause  is  removed.     Particular  emphasis  is 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     679 

laid  upon  this  point,  which  is  very  generally  overlooked,  because 
the  routine  treatment  of  the  "  pigeon-toes"  in  these  cases  might 
be  the  cause  of  direct  harm. 

Weak  Ankles.  ''Weak  ankle"  is  a  term  popularly  applied 
to  the  weak  foot  of  childhood,  in  which  the  foot  is  in  a  position 
of  valgus  when  in  use,  so  that  the  shoe  is  worn  away  on  its  inner 
side.  Weak  ankles  are  very  common  in  very  young  children 
and  are  often  one  of  the  results  of  general  weakness  due  to 
defective  assimilation.  At  this  age  the  foot  is,  in  addition,  usually 
flat  (Fig.  403),  but  in  the  valgus  or  weak  ankle  of  later  years 
the  arch  is  often  practically  normal  in  outline. 

Fig.  404. 


Congenital  flat-foot.    Rigid  deformity  of  an  extreme  type,  illustrating  the  component 
abduction  and  obliteration  of  the  arch. 


Outgrown  Joints.  In  older  children  prominent  or  "  out- 
grown "  joints  often  attract  the  mother's  attention  ;  the  internal 
malleoli  appear  prominent  because  of  the  position  of  valgus,  or 
because  of  the  turning  out  of  the  feet  the  malleoli  may  strike 
against  one  another,  "  interfere,"  and  thus  there  may  be  an  actual 
hypertrophy  of  the  projecting  bones  from  local  irritation. 

Another  type  is  the  long,  slender  foot,  in  which  the  navicular 
is  prominent  because  of  the  strain  and  pressure  put  upon  it  by 
the  improper  attitudes ;  its  position  is  often  shown  by  the  point 
of  wear  in  the  leather  of  the  shoe  (Fig.  402). 

In  the  weak  foot  of  childhood,  although  restriction  of  voluntary 


680 


ORTHOPEDIC  SURGERY. 


and  passive  motion  may  be  present,  there  are,  as  a  rule,  but  little 
local  tenderness  and  muscular  spasm,  and,  as  has  been  said,  but 
little  actual  pain.  Thus  it  differs  greatly  from  the  adult  type,  for 
the  reason  that  the  weak  foot  in  childhood  has  not  been  subjected 
to  the  strain  of  constant  occupation  or  to  the  burden  of  the  in- 
creased weight  of  the  body.  There  is  another  important  difference 
also ;  the  foot  of  the  adult  is  obliged  to  bear  greater  strain  than 
any  other  part,  and  although  normal  in  structure  it  may  be  over- 
strained, so  that  in  many  or  in  most  instances  the  weakness  of 
the  foot  may  be  the  only  disability.  But  in  childhood,  when 
such  exciting  causes  are  absent,  a  weak  foot  is  very  often  a  local 
indication  of  o-eneral  weakness  and  loss  of  tone. 

Fig.  405. 


Flat-foot ;  extreme  defonnity  in  childhood. 

Irregular  Forms  of  Weak  Feet.  Occasionally  the  apex  of 
the  inward  bulging  and  deformity  is  not  at  the  mediodorsal  joint, 
but  anterior  to  it  in  the  cuneiform  region.  In  such  cases  the 
internal  cuneiform  bone  may  be  enlarged  and  sensitive  to  pressure. 

Another  form  is  the  combination  of  a  plantar  flexed  toe  with  a 
depressed  arch  (Fig.  406).  Extreme  deformity  of  this  class  is 
usually  congenital.  A  milder  type  is  not  uncommon.  (See 
Hallux  Rigidus.) 

Weak  Feet  and  Deformity  of  the  Legs.  In  childhood  weak 
feet  are  often  seen  in  combination  with  slight  knock-knees  (Fig. 
403),  although  more  marked  knock-knee  usually  induces  in  com- 
pensation the  opposite  attitude  of  adduction.  (See  Knock-knee.) 
Bow-leg  in  childhood  is  usually  accompanied  by  slight  inward 
rotation  of  the  feet,  but  in  later  life  there  is  usually  a  certain 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      681 

degree  of  compensatory  valgus,  although  it  does  not,  as  a  rule, 
cause  discomfort. 

General  Weakness.  The  direct  effects  of  the  weak  and  pain- 
ful foot  have  been  described  in  detail.  It  must  be  borne  in  mind 
that  the  feet  are  the  foundation  of  the  body,  and  that  an  insecure 
foundation  affects  the  entire  mechanism.  General  functional 
weakness  and  awkwardness,  the  flat  chest,  round  shoulders,  or 
other  curvatures  of  the  spine,  are 
often  observed  as  accompaniments  ^^°-  ^°^- 

or  effects  of  weak  feet.  Thus,  as 
a  rule,  the  systematic  treatment 
of  any  form  of  postural  weakness 
must  include  the  treatment  of  the 
feet  as  well. 

Recapitulation.  The  disability 

and     deformity    of     the     weak    or         Hammer-toe  flat-foot.    (Nicoladoni.) 

so-called  flat-foot  are  caused  by 

a  disproportion  between  the  strength  of  the  foot  and  the  weight 

and  strain  to  which  it  is  subjected. 

The  foot  may  be  weakened  by  injury  or  disease;  it  may  be 
overburdened  by  the  body  weight,  or  overstrained  by  laborious 
occupation,  or  the  broken-down  foot  may  be  simply  one  indica- 
tion of  general  bodily  weakness.  It  is  unnecessary  to  enumerate 
all  the  various  factors  that  singly  or  combined  lead  to  this  dis- 
ability. It  may  be  stated,  however,  that  the  weak  foot  is  in 
many  or  most  instances  the  only  disability  that  demands  treat- 
ment. Its  most  constant  predisposing  causes  are  the  direct  injury 
caused  by  improper  shoes  and  the  mechanical  disadvantages  to 
which  it  is  subjected  by  the  assumption  of  improper  attitudes. 

All  weak  or  flat  feet  are  mechanically  weak,  but  all  weak 
feet  are  by  no  means  painful  feet.  Pain,  the  symptom  of  over- 
strain or  injury,  bears  no  definite  relation  to  the  degree  of 
deformity. 

In  certain  instances  exaggeration  of  the  arch  may  be  combined 
with  persistent  abduction  of  the  foot;  in  others,  the  flattening  of 
the  arch  may  be  the  most  noticeable  deformity,  but  in  most  cases 
the  two  are  combined  in  varying  degree.  And  as  each  deformity 
is  an  evidence  of  weakness,  it  seems  hardly  necessary  to  make  a 
radical  distinction  between  the  two,  except  as  regards  prognosis. 
For  the  abdueted  foot  in  which  the  arch  is  intact  is  almost  always 
an  accpiired  deformity  of  short  duration,  whereas  in  the  case  of 
the  foot  in  which   the  arch  is  obliterated  the  deformity  usually 


682  ORTHOPEDIC  SURGERY. 

dates  from  early  childhood,  and  it  is,  therefore,  far  less  amenable 
to  treatment  as  far  as  perfect  cure  is  concerned. 

Treatment.  The  principles  of  the  treatment  which  leads  to 
the  permanent  cure  of  the  weak  and  deformed  foot  are  very 
simple,  but  the  application  varies  somewhat  according  to  the 
grade  and  duration  of  the  deformity.  The  object  of  treatment  is 
to  so  change  the  weak  foot  that  it  may  conform  not  only  in 
contour  but  in  habitual  attitudes  and  in  power  of  voluntary 
motion  to  those  of  the  normal  foot,  because  complete  cure  is 
impossible  unless  normal  function  is  regained.  The  first  step 
must  be,  therefore,  to  make  passive  motion  free  and  painless  to 
the  normal  limit.  In  other  words,  the  obstructions  to  the  motion 
of  the  machine  must  be  removed  before  the  power  can  be  properly 
applied ;  for  the  increase  of  muscular  strength  and  ability,  on 
which  ultimate  cure  depends,  is  not  possible  while  motion  is 
restrained  by  deformity  or  by  pain  or  by  adhesions  or  contrac- 
tions. 

The  weak  foot,  because  of  inefficient  ligaments  and  muscles 
unable  to  hold  itself  in  proper  position,  must  be  supported,  in 
many  instances,  until  regenerative  changes  have  taken  place 
in  its  structure.  Such  support  is  necessary  to  retain  the  joints  in 
normal  position,  and  to  hold  the  weight  in  proper  relation  to  the 
foot,  otherwise  normal  function  is  impossible.  When  these  essen- 
tials are  provided  the  patient  may  cure  himself  by  the  proper 
functional  use  of  the  foot  and  by  the  avoidance  of  attitudes 
that  place  it  at  a  disadvantage. 

It  may  be  well  to  describe,  first,  the  treatment  that  must  be 
applied  to  all  classes  of  weak  foot  in  which  a  cure  is  to  be 
attempted,  and  which  by  itself  is  sufficient  in  the  milder  types, 
before  calling  attention  to  the  modifications  that  may  be  necessary 
in  special  cases. 

The  Shoe.  In  practically  all  cases  it  will  be  necessary  \o  pro- 
vide the  patient  with  a  proper  shoe,  for  the  shoe  is  usually  the 
direct  cause  of  the  minor  deformities,  and  indirectly,  in  many 
instances,  of  more  serious  disability.  Indeed,  most  of  the 
deformities  and  disabilities  of  the  foot  are  incidental  to  civiliza- 
tion and  are,  therefore,  confined  to  the  shoe-wearing  people.  The 
direct  effect  of  the  ordinary  shoe  is  to  lessen  the  area  and  the 
adjustability  of  the  fulcrum  by  cramping  the  toes  together.  Indi- 
rectly it  causes  deformities — corns,  bimions,  and  the  like — which 
serve  to  make  active  movement  or  leverage  painful,  so  that  it  is 
replaced  by  the  passive  attitude. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      683 


Fig.  407. 


The  proper  shoe  should  contain  sufficient  space  for  the  inde- 
pendent movements  of  the  toes.  This  motion  is  ilkistrated  in  the 
walk  of  the  barefoot  child.  As  the  weight  falls  on  the  foot  the 
toes  spread,  and  as  the  body  is  raised  on  the  foot  they  contract. 
The  imjDortant  leverage  action  of  the  great  toe  and  the  support 
afforded  by  it  to  the  arch  of  the  foot  have  been  mentioned  already. 
The  shape  of  the  sole  should  corre- 
spond to  the  shape  of  the  foot  and  the 
heel  should  be  broad  and  low  (Fig. 
407).  It  will  be  noted  that  the  front 
of  the  sole  of  the  shoe  in  the  figure 
(407)  appears  to  be  pointed  slightly 
inward.  Such  a  shoe  aids  in  prevent- 
ing abduction,  and  it  is  therefore  an 
important  adjunct  to  the  brace  in  re- 
straining deformity. 

Raising  the  Inner  Border  of  the  Shoe. 
A  simple  expedient  in  the  treatment 
of  the  weak  foot  and  an  aid  in  balan- 
cing it  properly  is  to  make  the  inner 
border  of  the  sole  and  heel  of  the  shoe 
slightly  thicker  in  order  to  throw  the 
weight  toward  the  outer  side  of  the 
foot.  This  is  of  special  importance 
in  the  treatment  of  the  slighter  degrees 
of  what  is  known  as  weak  ankle,  and 
it  is  always  of  service  in  the  treatment 
of  any  grade  of  weak  foot. 

Attitudes.  The  patient's  attention 
is  then  called  to  the  three  elements  of 
weakness.  He  is  instructed  to  guard 
against  valgus  (Fig.  391)  by  throwing 
the  weight  on  the  outer  side  of  the  foot 
(Fig,  392)  and  to  guard  against  ab- 
duction by  holding  the  feet  parallel  with  one  another  in  walking 
(Fig.  374)  ;  the  significance  of  the  bulging  on  the  inner  side  of 
the  foot  is  pointed  out  to  him,  and  how  this  may  be  prevented  by 
the  avoidance  of  the  postures  just  indicated,  and  by  aiding  the 
arch  by  the  power  of  the  great  toe.  The  importance  of  leverage 
is  shown  him,  that  he  must  try  to  press  down  the  sole  of  the 
shoe  with  his  toes,  and  employ  the  active  lift  of  the  calf  muscles 
by  fully  extending  the  leg  and  raising  the  body  on  the  foot  from 


The  proper  relation  of  the  sole  to 
the  shape  of  the  foot.  A,  outline  of 
sole:  B,  outline  of  foot;  C,  imprint 
of  foot. 


684  ORTHOPEDIC  SUBGERY. 

time  to  time  (Fig.  374).  Finally,  he  must  avoid  long  continuance 
in  one  position,  especially  the  passive  posture,  which,  even  in  the 
normal  subject,  simulates  the  attitude  and  deformity  of  weak  foot. 
In  short,  he  must  be  instructed  in  the  mechanics  of  the  foot  and 
taught  Iww  the  weak  foot  may  be  protected  as  well  as  strengthened. 

Exercises.  It  is  important,  also,  to  demonstrate  to  the  patient 
the  normal  range  of  motion  of  the  foot,  motion  which,  if 
restricted,  must  be  regained  by  voluntary  and  passive  exercises. 
Voluntary  exercise  should  be  devoted  to  strengthening  the  ad- 
ductors and  plantar  flexors ;  thus  the  foot  should  be  adducted 
and  supinated  then  dorsiflexed  in  the  attitude  of  slight  adduction 
(Fig.  378)  over  and  over  again  at  every  opportunity.  Tip-toe 
exercises  are  especially  useful ;  the  patient,  placing  the  feet  in 
the  attitude  of  moderate  inward  rotation,  raises  the  body  on  the 
toes  to  the  extreme  limit,  the  limbs  being  fully  extended  at  the 
knees,  then  sinking  slowly,  resting  the  weight  on  the  outer  bor- 
ders of  the  feet,  in  the  attitude  of  marked  varus,  twenty  to  one 
hundred  times.  This  exercise  is  somewhat  difficult,  and  it  cannot 
be  carried  out  properly  if  there  is  any  limitation  of  motion  or 
sensitiveness  at  the  mediotarsal  joints.  The  best  of  all  exercises 
is,  however,  the  proper  walk,  in  which  the  leverage  power  of 
the  foot  is  employed,  and  in  which  it  passes  through  the  proper 
alternation  of  postures  (Fig.  374).  Treatment  by  massage  and 
special  gymnastic  exercises  is,  of  course,  of  benefit  if  the  patient 
can  command  it,  although  by  no  means  essential  to  the  cure. 

Support.  In  many  instances  the  simple  treatment  that  has 
been  outlined  is  all  that  is  required,  and  the  symptoms  of  tire 
and  strain  are  quickly  relieved,  but  in  the  majority  of  cases  the 
patient  is  not  able  to  prevent  deformity  voluntarily  ;  consequently 
a  support  is  necessary  to  hold  the  foot  in  proper  position  and  to 
relieve  discomfort.  It  is  usually  necessary  in  the  treatment  of  the 
weak  foot  of  childhood  because  one  cannot  command  the  aid  of 
the  patient. 

In  selecting  a  support  for  the  weak  foot  the  nature  of  the 
deformity  that  is  to  Ibe  prevented  should  be  borne  in  mind ;  that 
the  acquired  flat-foot,  for  example,  is  not  a  direct  breaking  down 
of  the  arch,  as  is  usually  taught,  but  a  lateral  deviation  and  sink- 
ing— a  compound  deformity,  as  has  been  already  described  (Fig. 
393).  Thus  a  brace  to  be  efficient  must  hold  the  foot  laterally 
as  well  as  support  the  arch.  But  it  must  not  prevent  the  normal 
motions  of  the  foot,  and  thus  interfere  with  the  increase  of 
muscular  strength  and  ability,  on  which  ultimate  cure  depends. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      685 

The  supports  that  have  been  ordinarily  used  for  flat-foot  do 
not  fulfil  the  conditions  ;  the  pads  and  springs  placed  beneath  the 
arch  are  intended  to  support  it  by  direct  pressure  without  regard 
to  the  valgus  or  the  abduction ;  they  are  usually  ill-fitting,  and 
are  often  of  such  length  and  shape  as  to  splint  the  foot  and  thus 
to  restrict  its  motion.  Leg  braces  which  control  the  valgus  do 
not  often  hold  the  foot  accurately,  and  their  weight  and  unsight- 
liness  are  fatal  objections  to  their  use,  especially  so  in  the  early 

Fig.  408. 


The  attitude  in  which  the  plaster  cast  should  be  taken.  In  the  reproduction  the  chair 
upon  which  the  foot  is  resting  has  been  removed.  This  altitude  is  important,  because  in  it 
the  foot  assumes  the  best  possible  contour.  If  the  foot  is  simply  pressed  downward  into  the 
plaster  cream,  the  ordinary  method  of  making  the  model,  the  shape  will  be  found  to  be^quite 
different  from  that  taken  in  the  manner  illustrated. 

cases,  in  which  prevention  of  subsequent  deformity  is  of  such 
importance. 

A  brace  should  never  be  applied  to  a  deformed  and  rigid  foot 
because  it  cannot  adapt  itself  to  the  support;  the  spasm  and 
rigidity  must  be  first  relieved  by  preliminary  treatment,  that  will 
be  described  in  the  consideration  of  this  class  of  cases. 

The  Construction  of  the  Brace.  To  properly  construct  a  brace 
to  meet  these  conditions,  it  is  necessary  to  provide  tlie  mechanic 
with  a  plaster  cast  of  the  foot,  taken  in  the  attitude  in  which  one 


686  ORTHOPEDIC  SUBGEBY. 

wishes  to  support  it.     Such  a  model  may  be  easily  and  quickly 
made  in  the  following  manner : 

The  Plaster  Cast.  Seat  the  patient  in  a  chair ;  in  front  of  him 
place  another  chair  of  equal  height;  on  it  lay  a  thick  pad  of 
cotton-batting  and  cover  it  with  a  square  of  cotton-cloth.  Put 
about  a  quart  of  cold  water  into  a  basin  and  sprinkle  plaster  of 
Paris  on  the  surface  until  it  does  not  readily  sink  to  the  bottom ; 
then  stir.  When  the  mixture  is  of  the  consistency  of  very  thick 
cream  pour  it  upon  the  cloth.  The  patient's  knee  is  then  flexed, 
and  the  outer  side  of  the  foot,  previously  smeared  lightly  with 
vaseline,  is  allowed  to  sink  into  the  plaster,  and,  the  borders  of 
the  cloth  being  raised,  the  plaster  is  pressed  against  the  foot 
until  rather  more  than  half  is  covered.  The  foot  should  be  at  a 
right  angle  with  the  leg,  and  the  sole  should  be  in  the  plane 

Fig.  409. 


A,  the  astragalonavicular  joint.    The  internal  flange  of  the  brace  should  rise  well  above 
all  the  prominent  bones  to  a  point  about  half  an  inch  below  the  malleolus. 

perpendicular  to  the  seat  of  the  chair  (Fig.  408).  As  soon  as 
the  plaster  is  hard  its  upper  surface  is  coated  with  vaseline,  and 
the  remainder  of  the  foot  is  covered  with  plaster ;  the  two  halves 
are  then  removed,  smeared  lightly  with  vaseline,  and  bandaged 
together.  The  interior  is  dampened  with  soapsuds,  and  it  is 
then  filled  with  the  plaster  cream.  In  a  few  moments  the  plaster 
shell  may  be  removed,  and  one  has  a  reproduction  of  the  foot, 
which,  when  properly  made,  should  stand  upright  without  incli- 
nation to  one  side  or  the  other  (Fig.  412). 

In  most  instances  it  will  be  of  advantage  to  deepen  in  the 
plaster  model  the  inner  and  outer  segments  of  the  arch,  in  order 
that  the  arch  of  the  brace  may  be  slightly  exaggerated,  especially 
at  the  heel,  so  that  the  depression  of  the  anterior  extremity  of 
the  OS  calcis  may  be  prevented. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      687 

The  Brace.  Upon  the  model  the  outline  of  the  brace  is  drawn 
as  illustrated  in  the  diagrams.  The  best  sheet  steel,  18  to  20 
gauge,  cut  after  the  pattern  is  moulded  upon  it  and  tempered,  so 
that,  as  it  is  applied  for  the  purpose  of  preventing  deformity,  it 
may  be  practically  unyielding  to  the  weight  of  the  body. 

It  will  be  noticed  that  the  brace  clasps  the  weak  part  of  the  foot 
and  holds  it  together ;  the  broad  internal  upright  portion  (Fig. 
409)  covers  and  protects  the  astragalonavicular  junction,  rising 
well  above  the  navicular;  the  external  arm  covers  the  calcaneo- 


FlG.  410. 


Fig.  411. 


C,  the  great  toe-joint ;  D,  the  cen- 
tre of  the  heel. 


B,  the  calcaneocuboid  junction.  The  external  flange 
extends  from  the  centre  of  the  heel  to  a  point  just  be- 
hind the  base  of  the  fifth  metatarsal  bone. 

cuboid  junction  and  the  outer  aspect 
of  the  foot  to  a  height  sufficient  to 
hold  the  foot  securely  (Fig.  410).  The 
sole  part  provides  a  firm,  comfortable 
support,  yet,  reaching  only  from  the  cen- 
tre of  the  heel  to  just  behind  the  ball 
of  the  great  toe,  it  does  not  restrain  the 

normal  motions  of  the  foot  (Fig.  411).  The  brace  may  be  nickel- 
plated  and  japanned,  which  makes  a  smooth  finish,  or  tin-plated, 
or  galvanized,  which  makes  a  more  durable  covering.  It  may  be 
covered  with  leather,  or  an  inner  sole  may  be  placed  on  its  upper 
surface  ;  but  this  is  not  usually  necessary.  As  it  is  fitted  to  the 
foot,  it  finds  and  holds  its  own  place  in  the  shoe,  so  that  no  attach- 
ment is  required ;  thus  it  may  be  changed  from  one  shoe  to  an- 
other. Not  only  does  it  hold  the  foot  laterally  and  from  beneath, 
but  there  is  an  element  of  suggestiveness  in  the  slight  leverage 
action  which  is  very  important,  and  which  is  the  distinctive 
feature  of  this  brace  as  contrasted  with  simple  sole  plates  or 
other  supports. 

The  Positive  Action  of  a  Proper  Brace.     The  patient,  instructed 
to  throw  his  weight  upon  the  outer  side  of  the  foot  and  wearing 


688 


ORTHOPEDIC  SURGERY. 


the  shoe  which  has  been  tilted  in  the  same  direction  by  thicken- 
ing the  inner  border  of  the  sole  and  heel,  presses  down  the 
external  arm  and  thus  lifts  the  internal  flange  against  the  inner 
side  of  the  foot,  which  is  instinctively  drawn  away  from  the 
pressure  and  thus  toward  the  normal  contour.  He  no  longer 
everts  or  turns  the  feet  outward  in  walking,  because  this 
causes  positive  discomfort,  and  he  is  not  likely  to  assume  the 
passive  attitude,  because  of  the  suggestive  lateral  pressure  of  the 
support.  With  the  foot  held  in  the  proper  attitude  the  patient 
may  again  walk  with  the  proper  spring ;  thus  the  brace  itself 
becomes  a  positive  aid  in  the  physiological  cure.  It  is  important, 
also,  that  a  shoe  of  proper  shape,  as  shown  in  the  diagram  (I'ig. 
407)  be  worn,  as  it  aids  the  brace  by  holding  the  forefoot  in  a 
slightly  adducted  attitude. 


Fig.  412. 


A  cast  marked  for  the  mecbanic.  Iq  most  instances  the  internal  flange  is  lengthened  as 
in  this  diagram,  as  compared  with  Fig.  409,  in  order  to  straighten  the  support  so  that  light 
steel  (gauge  20)  may  be  used.    (See  Fig.  413.) 


The  shape  of  the  brace,  in  general  like  that  of  the  diagram,  is 
modified  in  certain  cases ;  for  instance,  the  entire  internal  aspect 
of  the  foot  may  be  weak  and  must  be  covered  by  the  internal 
flange.  In  very  heavy  subjects  the  sole  portion  must  be  made 
larger,  although  this  is  a  disadvantage,  as  it  lessens  the  leverage 
action;  other  slight  modifications  may  be  necessary  in  special 
cases.  If  any  portion  of  the  rim  of  the  plate  causes  discomfort, 
the  edge  may  be  turned  away  slightly  at  the  point  of  pressure  by 
a  wrench.  After  a  few  days  the  patient  no  longer  notices  the 
presence  of  the  brace,  aud  as  its  presence  in  the  shoe  is  not 
evident,  it  may  be  worn  indefinitely.  Steel  is  the  lightest  and 
strongest,  and,  on  the  whole,  the  most  satisfactory  material  for 
the  brace.     It  will,  of  course,  rust  in  time,  and  for  this  reason 


Fig.  413. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     689 

each  patient  should  be  provided  with  two  pairs  of  braces^  in  order 
that  the  rusted  pair  may  be  returned  to  the  bracemaker  for  repairs. 
In  hospital  practice  heavier  material  is  used  and  the  braces  are 
plated  with  tin,  which  is  fairly  resistant.^ 

It  is  usually  necessary  for  from  three  months  to  a  year  or 
longer,  according  to  the  condition  of  the  patient  and  the  strain  to 
which  the  feet  are  subjected.  The  brace,  properly  made  and 
adjusted  under  the  proper  conditions,  causes  no  more  pressure 
or  discomfort  than  a  well-made  shoe,  for  its  principle  is  quite 
different  from  that  of  the  ordinary  supports  that  are  in  common 
use,  to  which  this  objection  has 
been  made.  This  brace  supports 
the  arch  primarily  by  prevent- 
ing abduction,  consequently  its 
pressure  is  felt  upon  the  lateral 
aspect  of  the  foot,  a  pressure  that 
the  patient  can  relieve  by  im- 
proving his  attitude.  The  brace 
should  afford  support  when  neces- 
sary, and  at  all  times  suggest  and 
enforce  a  proper  attitude ;  it  is, 
however,  but  one  of  the  essential 
factors  in  the  general  scheme  of 
treatment.  The  ordinary  form  of 
brace  is  made  in  the  shape  of  an 
inner  sole,  as  in  the  diagram  (Fig. 
414).  As  it  supports  the  sole  of 
the  foot,  and  by  the  elevation  of 

its  inner  border  tends  to  throw  the  weight  more  toward  the  outer 
side;    it  is  a  useful  aid  in  treatment,  but,  providing  no  lateral 


The  outline  of  the  sole  part  of  the  brace. 


Fig.  414. 


The  sole  plate  ordinarily  used  in  the  treatment  of  weak  foot.    (After  Bradford  and  Lovett.) 

support,  it  cannot  prevent  the  inward  bulging  of  the  foot,  Avhich 
is  the  most  important  element  of  the  deformity. 

In  the  treatment  of  children  the  foot  should  be  moved  in  all 
direction.s,  }>ut  particularly  in  dorsal  flexion  and  adduction  to  the 


'  In  many  instances  there  is  a  rapid  improvement  in  the  shape  of  the  foot  under  treatment, 
and  It  is  often  advisable  Ut  maJte  a  second  cast  In  such  cases,  in  order  that  tlie  brace  may 
conform  to  the  improved  contour. 

44 


6 90  ORTHOPEDIC  S  UB  GEE  Y. 

full  limit  at  morDing  and  at  night,  until  the  child  has  regained 
the  normal  muscular  power  and  ability.  Special  gymnastics  and 
massage  are  always  desirable,  and  they  may  be  necessary  in 
certain  cases.  Bicycling  may  be  cited  as  one  of  the  best,  and 
roller-skating  as  one  of  the  worst  exercises  for  the  weak  foot. 
A  year  is  about  the  time  required  for  a  cure  of  the  weak  foot  in 
childhood,  although  attention  to  the  shoes  and  to  the  attitudes 
must  be  continued  indefinitely. 

The  Rigid  Weak  Foot. 

One  may  now  contrast  with  the  mild  types  of  weakness  that 
have  been  described  the  cases  of  extreme  deformity  in  which 
the  symptoms  are  disabling  and  in  which  the  foot  is  rigidly  held 
in  the  deformed  position  by  muscular  spasm  and  by  secondary 
changes  in  its  structure.  Such  cases,  often  considered  hopeless 
as  regards  a  cure  or  even  relief,  are  in  reality  the  most  satisfac- 
tory from  the  remedial  standpoint,  and  in  no  other  type  of  pain- 
ful deformity  can  so  much  be  accomplished  by  rational  treatment 
as  in  this  class.  The  deformity  must  be  considered  as  a  disloca- 
tion in  which  the  astragalus  has  slipped  downward  and  inward 
from  off  the  os  calois,  which,  in  turn,  is  tipped  downward  and 
inward  and  into  a  position  of  valgus.  The  remainder  of  the 
foot  is  turned  outward,  so  that  the  relation  of  the  leg  and  the 
forefoot  is  entirely  changed  ;  in  fact,  the  forefoot  is  almost 
entirely  disused  (Fig.  405). 

Corresponding  to  the  duration  of  the  disability,  one  finds 
accommodative  changes  in  the  soft  parts  and  in  the  bones,  but 
such  changes  are  by  no  means  as  marked  as  those  recorded  in  the 
reports  of  autopsies  which  have  been  made  in  cases  of  advanced 
and  irremediable  deformity.  In  fact,  by  far  the  greater  number  of 
patients  are  young  adults  in  whom  the  extreme  deformity  is  of  com- 
paratively short  duration,  and  in  whom  complete  cure  is  possible. 

In  the  treatment  of  such  a  condition  one  must  first  reduce  the 
dislocation  and  overcome  the  obstacles  that  contracted  muscles  and 
ligaments  may  offer  to  free  and  normal  motion ;  then  rest  must 
be  assured  to  the  injured  and  congested  parts  in  order  to  relieve 
the  patient  from  the  pain  from  which  he  has  suffered  so  long. 

Forcible  Overcorrection.  By  far  the  most  effective  treatment  is 
forcible  overcorrection  of  the  deformity,  under  anaesthesia.  When 
the  patient  is  under  the  influence  of  the  anaesthetic  the  muscular 
spasm  relaxes,  and  it  will  be  seen  that  this  accounts  for  about 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     691 

half  of  the  restriction  of  motion,  the  remainder  being  caused  by  the 
adaptive  changes  that  have  been  mentioned.  The  object  of  the 
operation  is  to  overcome  the  residual  obstruction,  and  to  assure 
the  patient  against  a  relapse,  by  fixing  the  foot  for  a  sufficient 
time  in  the  position  of  extreme  adduction  and  supination,  the 
attitude  directly  opposed  to  that  which  has  become  habitual. 

This  is  the  object  of  forcible  overcorrection  as  the  first  step  in 
the  systematic  repair  of  the  disabled  mechanism  ;  its  principle 
must  not  be  confounded  with  forcible  correction  carried  out  with 
the  object  of  simply  remoulding  the  arch  of  the  foot,  or  in  which 
the  simple  correction  of  the  deformity  is  the  object  in  view. 

One  first  extends  the  foot  forcibly,  then  flexes  it  to  the  normal 
limit,    then    abducts   and   adducts,    the   different    motions   being 


Fig.  415. 


Fig.  416. 


The  deformed  foot  before  operation.  A,  the 
projection  of  the  displaced  astragalus  and  navic- 
ular; B,  the  inner  malleolus;  C,  the  medio- 
tarsal  joint,  showing  the  outward  displacement 
before,  the  inward  rotation  behind,  this  point. 


The  overcorrected  foot,  showing  the  re- 
versal of  the  lines  of  displacement.  (See 
Fig.  417.) 


carried  out  over  and  over  until  the  rigid  foot  has  become  perfectly 
flexible.  In  cases  of  long  standing  it  is  often  necessary  to  draw 
the  patient  to  the  end  of  the  table,  so  that  the  foot  may  be  taken 
between  the  knees,  in  order  to  supply  the  required  force  by  the 
thigh  muscles.  This  forcible  manipulation  is  accompanied  by  the 
audible  breaking  of  adhesions,  and  in  favorable  cases  by  complete 
disappearance  of  the  deformity.  In  certain  instances  it  will  be  neces- 
sary to  divide  the  tendo  Achillis,  when,  for  example,  the  range  of 
dorsal  flexion  is  limited  by  resistant  accommodative  shortening  of 
the  calf  muscles,  or  when  there  has  been  very  great  pain  and  tender- 
ness at  the  mediotarsal  joint,  and  it  is  desired  to  remove  the  strain 


692  ORTHOPEDIC  SURGEBY. 

of  leverage  completely  ;  traumatic  cases  come  especially  under  this 
head.  Tenotomy  has  on§  great  advantage  :  it  necessitates  longer 
fixation  in  the  plaster  bandage,  and  gives  the  patient  the  benefit 
of  rest,  and  the  opportunity  for  prolonged  after-treatment.  When 
the  passive  range  of  motion  has  been  regained,  the  foot  is  turned 
downward,  then  inward  and  upward  into  the  position  of  extreme 
varus.  By  this  manipulation  the  os  calcis  is  drawn  under  the 
astragalus  and  thrown  into  the  supinated  position,  and  the 
scaphoid  is  flexed  about  and  under  the  head  of  the  astragalus, 
which  is  then  lifted  to  the  limit  of  normal  flexion.  The  attempt 
is  always  made  to  briag  the  extreme  outer  border  of  the  inverted 
foot  up  to  a  right  angle  with  the  leg,  which  is  the  limit  of  normal 
flexion  in  this  attitude.  The  foot,  thickly  padded  with  cotton, 
especially  about  the  toes,  is  then  fixed  in  this  posture  of  club-foot 
by  a  firm  plaster-of-Paris  bandage  extending  to  the  knee  (Fig.  407). 
Surprisingly  little  discomfort,  considering  the  force  that  it  is  some- 
times necessary  to  apply,  is  experienced  after  the  operation.  The 
familiar  and  often  intense  pain,  from  which  the  patient  has  suffered 
so  long,  is  entirely  relieved  by  the  correction  of  the  deformity; 
there  is  often  a  sense  of  tension  about  the  outer  side  of  the  ankle 
and  dorsum  of  the  foot,  but  this  is  not,  as  a  rule,  of  long  duration. 

Functional  Use  in  the  Overcorrected  Attitude.  As  soon  as  pos- 
sible, often  on  the  following  day,  the  patient  is  encouraged  to 
stand  and  walk,  bearing  his  weight  on  the  foot.  Walking  serves 
two  purposes :  to  still  further  overcorrect  the  deformity,  and  to 
accustom  the  patient  to  a  posture  entirely  different  from  that  so 
long  assumed.  Meanwhile  the  contracted  tissues  on  the  outer 
side  become  thoroughly  overstretched;  the  weakened  ligaments 
and  muscles  on  the  inner  side  are  relaxed,  and  the  local  irritation 
rapidly  subsides  under  the  rest  from  the  constant  injury  to  which 
the  foot  has  been  subjected. 

The  patient  is  not  confined  to  the  bed  or  house,  although  if 
both  feet  are  in  plaster  bandages  crutches  are,  of  course,  neces- 
sary. The  time  that  the  feet  should  remain  in  the  overcorrected 
position  depends  upon  the  duration  of  the  deformity  and  the 
severity  of  the  symptoms,  or  from  two  to  six  weeks,  the  usual 
time  being  about  four  weeks.  At  the  end  of  about  three  weeks, 
or  whenever  the  patient  can  support  the  weight  on  the  plaster 
bandage,  without  a  sensation  of  discomfort,  it  is  removed ;  the 
foot  is  placed  in  the  normal  attitude  and  a  cast  is  taken  for  the 
brace  (Fig.  408).  Immediately  after,  the  foot  is  returned  to 
the  club-foot    position    and    the   plaster  bandage    is    reapplied. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      693 


When  the  brace  is  ready  the  plaster  bandage  is  finally  removed ; 
the  foot  is  now  in  good  position,  and  in  many  instances  the  arch 
is  exaggerated  in  depth.  For  the  first  few  days  prolonged  soak- 
ing in  hot  water  or  the  use  of  the  hot-air  bath,  with  subsequent 
massage  at  intervals  during  the  day,  will  be  found  useful  in  over- 
coming the  swelling  and  local  tenderness  that  may  remain.  It  is 
always  insisted  that  a  new  shoe  of  the  Waukenphast  pattern 
shall  be  obtained,  the  sole  and  heel  of  which  are  raised  a  quarter 
of  an  inch  on  the  inner  border 

to  aid  in  the  balancing  of  the  fig.  417. 

weak  foot.  The  brace  is  then 
applied,  and  the  patient  is 
never  allowed  to  walk  with- 
out its  support.  When  the 
shoe  is  removed  at  night,  he 
is  instructed  to  turn  the  toes 
in  and  to  bear  the  weight  on 
the  outer  side  of  the  foot  until 
it  has  regained  its  strength ;  in 
other  words,  the  deformity  is 
never  allowed  to  recur. 

Systematic  Manipulation. 
The  systematic  treatment  is 
then  begun  by  the  surgeon 
and  the  patient,  the  first 
essential  being  the  attainment 
of  free  and  painless  passive 
motion  in  all  directions. 
These  motions,  which  have 
been  so  long  restrained  by 
deformity,  cannot  be  regained 
without  effort,  and  during  this 

critical  stage,  treatment  must  be  carried  out  by  the  surgeon  him- 
self ;  if  he  trusts  to  the  patient  or  to  his  friends  a  cure  is  out  of 
the  question.  At  least  once  a  day  the  full  range  of  motion  must 
be  carried  out  to  the  normal  limit.  Three  motions — abduction, 
flexion,  and  extension — are  usually  free  and  painless ;  but  the 
fourth,  that  of  adduction,  is  almost  invariably  resisted  by  the 
same  quality  of  muscular  rigidity  that  was  present  before  the 
operation.  By  far  the  most  effective  method  of  overcoming  this 
resistance  is  conducted  as  follows  :  The  patient  being  seated  in 
a  chair,  the  surgeon  sits  or  stands  before  him.     Let  us  suppose 


The  forcible  overcorrection  of  flat-foot.    The 
proper  position  in  the  plaster  bandage. 


694  ORTHOPEDIC  SURGERY. 

that  the  left  foot  is  to  be  adducted  or,  as  the  patients  express  it, 
twisted.  The  surgeon  places  the  foot  between  his  knees  ;  his  left 
hand  encircles  the  heel,  the  fingers  grasping  the  projecting  os  calcis 
and  tendo  Achillis;  the  base  of  the  palm  lies  against  the  medio- 
tarsal  joint  on  the  inner  and  inferior  aspect  of  the  foot ;  the  right 
hand  grasps  the  outer  side  of  the  forefoot  and  toes ;  then,  by 
steady  pressure  of  the  thigh  muscles,  the  forefoot  is  forced  down- 
ward and  inward  (adducted  and  supinated)  (Fig.  338)  over  the 
fulcrum  formed  by  the  projecting  palm,  which  lies  upon  the  left 
knee,  the  fingers  holding  the  heel  steadily  in  place.  This  inward 
twisting  is  at  first  resisted  by  a  mixed  voluntary  and  involuntary 
muscular  spasm,  which  gradually  gives  way  under  steady  press- 
ure. When  the  limit  of  adduction  has  been  reached,  the  foot 
is  held  firmly  until  all  pain  has  subsided ;  then  the  patient  is 
instructed  to  attempt  voluotary  movements  while  the  foot  is 
guided  by  the  hands ;  in  other  words,  the  patient  attempts  to 
adduct  the  foot  while  the  surgeon  supplies  the  power,  which  in 
all  cases  of  this  type  has  been  completely  lost.  This  passive 
manipulation  to  the  extreme  limit  of  normal  adduction,  plantar 
and  dorsal  flexion,  is  continued  from  day  to  day  until  there  is  no 
longer  a  sensation  of  pain  or  tension.  For  as  long  as  there  is  the 
slightest  spasm  or  painful  restriction  of  passive  motion,  the  vol- 
untary assumption  of  proper  attitudes  is  checked,  and  until  this 
power  is  regained  there  is  danger  of  relapse.  During  active 
treatment,  therefore,  the  patient,  by  means  of  massage  and  active 
and  passive  exercises,  must  constantly  work  to  one  end,  namely, 
to  regain  the  lost  power  of  voluntary  adduction. 

The  time  necessary  to  rest  the  feet,  to  overcome  the  local 
irritation  and  muscular  spasm,  to  regain,  in  part  at  least,  the 
range  of  passive  motion,  and  to  place  the  patient  in  the  same 
position,  as  regards  a  cure,  as  in  the  milder  types  of  defor- 
mity, is  from  three  to  six  weeks.  Usually  the  patients  are  told 
that  a  month  will  be  necessary,  and  that  at  the  end  of  that  time 
they  may  return  to  work,  free  from  pain  and  from  the  danger  of 
relapse,  and  that  the  feet  will  constantly  grow  stronger  under 
the  work  which  was  before  too  great  for  their  strength.  The 
time  necessary  to  re-educate  the  adductor  muscles  in  their  proper 
function  depends,  in  great  degree,  upon  the  intelligence  and  per- 
sistence of  the  patient.  Although  in  after-treatment  massage  and 
special  exercises  are  of  benefit,  the  essentials  are  very  simple ; 
they  are  an  effective  brace,  a  proper  shoe,  the  passive  manip- 
ulation that  has  been  described  until  its  object  has  been  attained. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      695 

and  the  proper  walk,  the  best  and  easiest  of  exercises.  .Finally, 
one  must  force  into  the  patient's  understanding  the  method  of 
protecting  the  weak  foot  by  the  alternation  of  strain,  and  by 
proper  postures. 

Other  Varieties  of  Rigid  Weak  Foot.  The  foot  which  is 
fixed  in  the  abducted  position  without  depression  of  the  longi- 
tudinal arch  is  simply  one  variety  of  the  rigid  weak  foot,  which 
should  be  treated  in  the  same  manner.  It  may  be  stated,  also, 
that  a  very  large  proportion  of  the  so-called  chronic  sprains  of 
the  ankle  are  of  this  type,  and  that  the  disability  will  yield  very 
readily  to  treatment,  conducted  for  the  purpose  of  restoring 
impaired  function,  in  the  manner  that  has  been  indicated. 

In  certain  instances  the  apex  of  the  deformity  lies  in  front 
of  the  astragalonavicular  joint,  in  the  naviculocuneiform  region, 
and  the  internal  cuneiform  bone  may  be  enlarged  and  sensitive 
to  pressure.  Such  cases  should  be  treated  on  the  same  general 
principles  as  the  ordinary  variety. 

In  rare  instances  marked  depression  of  the  arch  is  accompanied 
by  flexion  contraction  of  the  great  toe,  as  if  the  result  of  an 
attempt  to  support  the  weak  arch.  This  was  described  by 
Nicoladoni  as  hammer-toe  flat-foot  (Fig.  406).  The  association 
of  painful  great  toe  (hallux  rigidus)  and  weak  foot  is  mentioned 
elsewhere  (page  718). 

There  are  other  cases  in  which  the  deformity  of  flat-foot  is 
complicated  by  rheumatoid  arthritis  or  chronic  rheumatism,  of 
which  the  evidence  is  seen  in  various  joints,  but  in  which  the 
pain  and  discomfort  seem  to  be  concentrated  in  the  feet,  which 
are  absolutely  stiff  and  deformed.  In  such  cases  one  can  hardly 
expect  a  complete  cure ;  but  although  the  function  of  leverage 
may  not  be  regained,  still  one  may  hope,  by  overcoming  the 
deformity,  to  hold  the  weight  of  the  body  in  its  proper  relation 
to  the  foot,  so  that  the  pain  of  a  progressive  dislocation  may  not 
be  added  to  the  pain  of  disease.  In  a  number  of  instances 
forcible  correction  has  been  employed  by  the  writer  in  cases  of 
this  type,  and  in  all  the  improvement  in  the  general  condition, 
consequently  in  the  resistance  to  the  disease,  after  the  relief  of 
the  local  pain  and  discomfort,  has  been  very  great. 

Between  the  two  classes  of  cases,  the  mild  and  the  severe,  one 
finds  every  grade  of  deformity.  All  cases  in  which  there  is 
marked  muscular  spasm,  local  tenderness,  and  swelling  require 
temporary  rest ;  in  many  instances  simply  rest  from  functional 
use  combined  with  massage ;  in  others,  rest  in  a  plaster  bandage 


696  ORTHOPEDIC  SURGERY. 

in  the  adducted  position.  In  the  milder  and  ordinary  class  of 
cases  the  use  of  a  brace  and  shoe  will  alone  relieve  spasm  and 
pain,  and  the  range  of  motion  can  usually  be  regained  by 
manipulation,  passive  motion,  and  by  the  proper  use  of  the  foot. 

Occasionally,  even  in  childhood,  one  may  encounter  marked 
limitation  of  normal  motion,  particularly  in  dorsal  flexion,  not 
due  to  pain  and  muscular  spasm,  but  to  actual  shortening  of  the 
muscle.  This  may  be  the  accommodative  shortening  that  is 
characteristic  of  long-standing  deformity ;  in  other  instances  it 
would  appear  to  be  the  result  of  a  slight  and  unnoticed  neuritis 
or  anterior  poliomyelitis,  which  has  resulted  in  muscular  inequal- 
ity. If  the  contraction  does  not  yield  readily  to  manipulation  or 
to  mechanical  stretching,  forcible  correction,  and,  if  necessary, 
tenotomy  should  be  employed  in  the  manner  already  described ; 
for  whatever  may  be  the  theory  of  its  causation  it  is  again 
emphasized  that  obstruction  to  motion  in  any  direction  must  be 
overcome  before  a  complete  cure  is  possible. 

Adjuncts  in  Treatment.  It  must  be  apparent  that  in  many 
instances  the  cure  of  the  weak  foot  is  out  of  the  question,  either 
because  of  the  want  of  energy  or  opportunity  on  the  part  of  the 
patient,  or  because  of  the  local  or  general  conditions,  types 
familiar  in  out-patient  practice. 

The  Thomas  Treatment.  In  such  cases  raising  and  strengthen- 
ing the  inner  side  of  the  shoe  by  the  wedge-shaped  leather  sole, 
as  used  by  Thomas,  splints  the  painful  foot  and  aids  in  relieving 
the  strain. 

Plaster  Strapping.  If  the  symptoms  are  more  acute  the 
adhesive  plaster  strapping,  as  advocated  by  Cottrell  and  Gibney 
for  the  treatment  of  sprains,  is  often  of  service,  although  it  is 
applied  in  a  different  manner,  and  with  a  different  object  in 
view.  One  end  of  a  strip  of  adhesive  plaster,  about  fifteen  inches 
long  and  three  inches  wide,  is  applied  to  the  outer  side  of  the 
ankle  just  below  the  external  malleolus  ;  the  foot  is  then  adducted 
as  far  as  possible,  and  the  band  is  drawn  tightly  beneath  the 
sole  and  up  the  inner  side  of  the  arch  and  leg,  and  is  stayed  in 
this  position  by  one  or  two  plaster  strips  about  the  calf.  Narrow 
plaster  straps  are  then  applied  about  the  arch  and  ankle,  in  the 
figure-of-eight  manner,  and  a  bandage  is  applied.  The  manner  of 
application,  although  not  the  attitude,  is  shown  in  Fig.  266.  The 
object  of  the  dressing  is  to  aid  in  holding  the  foot  in  the  proper 
position  by  the  support  and  suggestiveness  of  the  plaster,  and  to 
provide  the  firm  compression  about  the  arch  that  is  always  agree- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      697 

able  to  the  sufferer  from  weak  foot.  This  treatment,  combined 
with  the  built-up  shoe,  is  often  very  effective  in  overcoming  the 
acute  and  disabling  symptoms  of  the  weak  and  injured  foot,  which 
are,  as  has  been  stated,  often  the  result  of  extra  strain  or  injury ;  in 
other  words,  a  sprain  of  a  weak  foot.  Consequently,  when  these 
symptoms  are  relieved,  the  patient  who  has  become  habituated 
to  the  weakness  and  deformity,  considers  himself  cured.  By  per- 
sistent manipulation  and  subsequent  support  with  the  adhesive 
plaster  one  may  overcome  the  resistance  to  deformity  in  the 
majority  of  cases.  Forcible  correction  under  anaesthesia  is,  how- 
ever, preferable. 

Operative  Treatment.  The  various  cutting  operations  for  the 
relief  of  flat-foot  do  not  call  for  extended  comment.  The  typical 
operation,  the  removal  of  a  wedge  from  the  astragalonavicular 
region,  aims  simply  at  removal  of  the  deformity.  It  should  be 
restricted  to  those  cases  in  which  the  adaptive  changes  are  so 
marked  that  functional  cure  is  impossible. 

Arthrodesis.  To  fix  the  foot  at  the  astragalonavicular  articula- 
tion in  the  attitude  of  slight  adduction  is  a  useful  aid  in  restrain- 
ing deformity  of  the  valgus  type  in  paralytic  disability,  and  it 
may  be  of  service  in  the  treatment  of  certain  cases  of  weak  foot 
of  a  slighter  grade  in  the  class  of  patients  not  amenable  to  ordi- 
nary treatment. 

The  operation  of  advancement  of  the  posterior  extremity  of  the 
OS  calcis,  as  proposed  by  Gleich,  in  order  that  it  may  be  placed 
in  relation  to  the  leg  somewhat  like  that  of  a  Pirogoff  amputa- 
tion, offers  little  hope  of  ultimate  cure.  For  since  the  disability 
is  not  due  to  primary  depression  of  the  arch,  it  can  hardly  be 
cured  by  exaggerating  its  depth  in  this  manner.  Supramalleolar 
osteotomy,  in  which  the  bones  of  the  leg  are  divided  above  the 
ankle,  and  the  distal  extremity  turned  inward,  with  the  aim  of 
directing  the  weight  toward  the  outer  border  of  the  foot,  has  been 
advocated  by  Trendelenburg.  In  practice  the  operation  is  by  no 
means  always  successful,  while  the  bow-leg  deformity  that  results, 
if  the  object  is  attained,  is  an  unfortunate  accompaniment  of  the 
treatment.  It  may  be  mentioned  in  this  connection  that  fracture 
at  the  ankle-joint,  followed  by  faulty  union  in  a  position  of  valgus, 
is  a  form  of  traumatic  flat-foot  that  may  be  cured  by  this  opera- 
tion. In  operative  treatment  the  element  of  rest,  necessary  for 
weeks  or  months,  must  be  taken  into  consideration,  as  explaining 
in  part  the  immediate  favorable  effect  of  whatever  procedure  is 
adopted. 


698  ORTHOPEDIC  SURGERY. 

In  conclusion,  the  following  points  are  again  emphasized : 
Flat-foot  in  its  surgical  sense  is  a  compound  deformity,  in  which 
the  abnormal  relation  between  the  foot  and  the  leg,  causing  the 
improper  distribution  of  the  weight  and  the  strain  and  disuse  of 
normal  function,  is  of  vastly  greater  importance  than  the  depres- 
sion of  the  arch,  which  has  given  the  name  to  the  disability. 

The  weak  and  deformed  foot  can  be  cured,  but  only  by  the 
application  of  the  simple  principles  that  any  mechanic  would 
apply  to  a  disabled  machine  whose  structure  and  use  were  known 
to  him.  In  other  words,  there  can  be  no  permanent  cure  of  weak- 
ness and  deformity  unless  normal  function  is  regained,  or  effective 
treatment  unless  it  has  this  end  in  view. 

The  term  weak  foot  has  this  advantage  over  others  that  imply 
deformity,  in  that  it  may  be  properly  applied  to  the  earliest  in- 
dications of  disability.  Once  weakness  is  recognized,  its  causes 
may  be  analyzed  and  appreciated  at  their  proper  value.  Flat-foot 
is  a  particularly  objectionable  and  misleading  term,  and  it  should 
be  discarded  or  at  least  used  only  to  describe  those  cases  to  which 
it  can  properly  be  applied. 


CHAPTER    XXI. 

DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT  (Coi^tinued). 

The  Hollow  or  Contracted  Foot. 

Synonyms.  Non-deforming  club-foot,  talipes  arcuatus,  talipes 
plantaris,  talipes  cavus. 

The  depth  of  the  arch  and  the  corresponding  area  of  the  bear- 
ing surface  of  the  sole  of  the  foot  vary  greatly  in  different 
individuals,  and,  although  marked  differences  in  appearance  and 
function  are  possible  within  a  normal  range,  yet,  as  a  rule,  the 
low  arch  is  characterized  by  a  certain  relaxation  and  weakness  of 
structure,  while  the  exaggerated  arch  implies  a  corresponding 
contraction  and  loss  of  normal  elasticity. 

The  hollow  or  contracted  foot  may  be  divided  into  two  classes 
— the  primary  and  the  secondary.  In  the  first  class  the  simple 
exaggeration  of  the  arch  (talipes  arcuatus)  is  the  only  change 
from  the  normal  condition.  In  the  second  the  high  arch  is  com- 
bined with  a  certain  limitation  of  the  range  of  dorsal  flexion  at 
the  ankle-joint  (talipes  plantaris — Fisher). 

Etiology.  The  simple  hollow  foot  may  be  an  inherited  pecu- 
liarity. The  depth  of  the  arch  may  be  exaggerated  by  the 
habitual  use  of  high  heels  (postural  equinus),  or  by  excessive  use 
of  the  calf  muscles,  as  by  professional  dancers. 

The  secondary  variety,  in  which  the  hollow  foot  is  combined 
with  slight  equinus,  is  usually  acquired,  and  in  the  majority  of  cases 
its  origin  may  be  traced  to  a  mild  and  transient  form  of  anterior 
poliomyelitis  or  neuritis  in  early  childhood.  This  causes  tem- 
porary weakness  of  the  anterior  group  of  muscles  of  the  leg,  and 
thus  a  slight  toe-drop,  followed  by  secondary  contraction  of  the 
tissues  of  the  sole  and  of  the  muscles  of  the  calf.  In  the  history 
of  many  of  these  patients  it  will  appear  that  after  recovery  from 
scarlatina  or  other  contagious  or  infectious  disease  the  child 
seemed  weak  or  awkward.  These  symptoms  became  less  marked 
or  practically  disappeared  ;  yet  a  trace  remained,  although  not 
of  sufficient  importance  to  call  for  treatment,  until  adolescence  or 
adult  life,  when  the  greater  strain  and  weight  put  upon  the  feet 


700 


OR THOPEDIC  SUBGEB  Y. 


brought  to  light  the  latent  disability.  The  affection  may  un- 
doubtedly develop  in  later  years  as  the  result  of  neuritis,  or  of 
gout  or  rheumatism.  It  may  be  caused  by  a  sprain  or  fracture 
of  the  ankle,  and  it  may  be  a  result  of  habitual  posture  to  com- 
pensate for  a  leg  shortened  by  injury  or  disease. 

The  exaggerated  arch  Avhich  is  a  part  of  a  more  important 
deformity,  as  of  equinovarus  or  calcaneus,  or  that  which  is  simply 
a  part  of  the  general  deformity  caused  by  diseases  of  the  nervous 
apparatus,  does  not  belong  to  the  class  of  disability  under  con- 
sideration. 


Fig.  418. 


The  contracted  foot  of  slight  degree. 


Symptoms.  The  simple  hollow  foot  often  exists  without 
symptoms ;  in  fact,  it  is  often  considered  as  a  particularly  well- 
formed  foot  rather  than  a  deformity.  The  usual  complaint  in 
these  cases  is  that  one  is  unable  to  buy  comfortable  shoes  because 
the  ordinary  shoe  does  not  support  the  arch,  or  because  the  upper 
leather  exerts  uncomfortable  pressure  on  the  dorsum  of  the  foot. 
The  convexity  of  the  dorsum,  of  course,  corresponds  to  the  depth 
of  the  arch,  and  in  many  instances  the  cuneiform  bones  project 
sharply  beneath  the  skin,  and  painful  pressure  points  or  even 
inflamed  bursse  in  this  locality  may  cause  discomfort. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      701 

In  the  well-marked  cases  in  which  the  weight  is  borne  entirely 
on  the  heel  and  the  front  of  the  foot,  calluses  and  corns  usually 
form  at  the  centre  of  the  heel  and  beneath  the  heads  of  the 
metatarsal  bones.  The  patient  may  complain  of  neuralgic  pain 
about  the  great  toe,  the  metatarsal  arch,  or  in  the  sole  of  the  foot. 
The  gait  is  often  ungraceful,  as  the  patient  walks  heavily  upon 
the  heels  with  the  feet  turned  outward.  In  such  cases  ' '  the 
ankles  may  be  weak  and  turn  easily."  In  the  more  advanced 
cases  of  this  type  the  foot  may  assume  the  position  of  valgus 
when  weight  is  borne,  so  that  the  more  noticeable  symptoms  are 
those  of  the  weak  foot  or  so-called  flat-foot,  even  though  the 
depth  of  the  arch  is  exaggerated. 

Fig.  419. 


Contracted  foot,  marked. 


Contracted  foot,  of  the  more  severe  grade,  is  almost  always 
accompanied  by  a  certain  limitation  of  dorsal  flexion ;  and  as  the 
shortening  of  the  plantar  fascia  is  often  more  marked  at  its  inner 
border,  a  slight  inversion  of  the  forefoot  or  varus  may  be  present 
also. 

When  the  exaggerated  arch  is  combined  with  limitation  of 
dorsal  flexion  the  deformity  is  usually  greater.  This  limitation 
may  be  very  slight,  or  it  may  be  well  marked  ;  and  a  slight 
degree  of  permanent  equinus  even  may  be  present,  but  so  slight  as 
it  does  not,  as  a  rule,  attract  attention. 


702  OR  THOPEDIC  S  UR  GER  Y. 

This  type  of  the  contracted  foot  was  first  clearly  described  by 
Shaffer  in  1885  under  the  title  of  "  non-deforming  club-foot,"^ 
and  later  by  Fisher,  of  London,  as  "  talipes  plantaris." 

The  symptoms  are  similar  to  those  of  the  simple  hollow  foot, 
but  they  are  almost  always  more  marked.  The  gait  is  awkward 
and  jarring,  the  feet  being  turned  outward  to  an  exaggerated 
degree.  The  patient  is  easily  fatigued,  and  often  complains  of  the 
weakness  about  the  ankle  and  inner  side  of  the  arch,  characteristic 
of  the  weak  foot,  and  of  sensations  of  tire  and  strain  in  the  calf 
of  the  leg.  The  discomfort  from  corns,  the  pain  referred  to  the 
metatarsal  region,  the  great  toe,  and  to  the  sole  of  the  foot  have 
been  described  already. 

On  examination  the  exaggeration  of  the  arch  is  evident,  and 
an  imprint  of  the  sole  shows  that  the  weight  is  borne  entirely  on 
the  heel  and  on  the  heads  of  the  metatarsal  bones,  which  may  be 
very  prominent  beneath  the  thickened  skin,  as  if  the  subcutaneous 
pad  of  fat  had  been  absorbed.  The  anterior  metatarsal  arch  is 
often  obliterated,  and  the  toes  are  usually  habitually  dorsiflexed 
at  the  first  phalanges,  the  permanent  flexion,  with  the  resulting 
pressure  against  the  leather  of  the  shoe  being  indicated  by  a  row 
of  corns  upon  their  dorsal  surfaces  (Fig.  419). 

The  contracted  plantar  fascia  may  be  demonstrated  by  forcible 
dorsal  flexion  of  the  foot,  when  the  tense  bauds,  in  many  instances 
very  sensitive  to  pressure,  may  be  felt  beneath  the  skin. 

On  testing  the  motion  of  the  foot,  the  limitation  of  dorsal 
flexion,  both  of  the  voluntary  and  the  passive  range,  will  be 
evident.  In  voluntary  flexion  the  toes  are  drawn  up  and  the 
tendons  are  plainly  seen  on  the  dorsum,  showing  the  effort  made 
by  the  accessory  muscles  to  overcome  the  abnormal  resistance. 

The  limitation  of  dorsal  flexion  may  be  demonstrated  in  the 
manner  suggested  by  Shaffer,  by  asking  the  patient  to  flex  the 
feet  while  standing  erect  with  the  back  to  the  wall,  when,  in  spite 
of  the  effort  made,  "  the  feet  remain  glued  to  the  floor." 

Treatment.  In  the  ordinary  form  of  contracted  foot,  as  has 
been  stated,  the  disability  is  much  more  marked  than  the  defor- 
mity ;  and  the  disability  is  due  to  secondary  changes  in  the  struc- 
ture of  the  foot,  by  which  its  elasticity  is  impaired.  If  this  can 
be  restored  in  some  degree  permanent  relief  will  follow.  If  the 
simple  hollow  foot  (cavus),  or  the  secondary  type  (plantaris), 
were   discovered    in   early   childhood,    massage  and    methodical 

1  New  York  Medical  Record,  May  23, 1885. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      703 

stretching  would,  in  all  probability,  be  sufficient  to  relieve  the 
contractions ;  but,  as  a  rule,  no  symptoms  are  noticed  until  later 
life.  Even  then,  especially  in  the  simple  form,  they  are  often 
slight  and  may  be  relieved  by  a  shoe  with  a  broad  heel  and  a  high 
(Spanish)  arch  or  by  a  foot  plate  that  equalizes  the  pressure  on 
the  sole. 

In  the  more  advanced  cases  of  the  milder  type  methodical 
forcible  manual  stretching  of  the  parts  may  elongate  the  tissues 
sufficiently  to  relieve  the  symptoms.  The  Shaffer^  "  traction 
shoe  "  may  be  used  with  advantage  for  the  same  purpose.  In 
the  more  resistant  cases,  however,  division  of  the  contracted  parts 
and  forcible  correction  of  deformity  is  indicated. 

Operative  Treatment.  The  patient  having  been  ansesthetized, 
a  tenotomy  knife  is  introduced  beneath  the  skin  to  the  inner  side 
of  the  central  band  of  fascia.  This  is  divided  by  a  sawing 
motion,  and  if  on  forced  dorsal  flexion  other  tense  bands  appear 
they  are  divided  also.  Forcible  massage,  with  the  aim  of  making 
the  foot  flexible  and  reducing  the  depth  of  the  arch,  is  then 
employed.  If  sufficient  force  cannot  be  employed  by  the  hands, 
the  Thomas  wrench  may  be  used  as  in  the  treatment  of  club-foot ; 
the  object  being  to  elongate  the  foot,  to  remove  the  contraction, 
and  thus  by  increasing  the  area  of  bearing  surface  to  relieve  the 
painful  pressure  on  the  heads  of  the  metatarsal  bones.  If  the 
contraction  of  the  tendo  Achillis  cannot  be  overcome  by  forcible 
manipulation  it  may  be  divided.  The  foot,  held  in  an  attitude 
of  dorsal  flexion,  is  then  fixed  in  a  well-fitting  plaster  bandage,  a 
thin  board,  shaped  to  the  foot,  having  been  incorporated  in  the 
bandage,  in  order  that  firm  and  even  pressure  may  be  exerted 
upon  the  sole.  As  soon  as  possible,  often  on  the  following  day, 
the  patient  is  encouraged  to  walk  about,  in  order  that  the  pressure 
of  the  body  weight  may  be  utilized  to  flatten  the  foot  still  more, 
while  its  tissues  are  in  a  yielding  condition. 

The  bandage  may  be  worn  for  six  weeks,  or,  if  the  tendo 
Achillis  has  been  divided,  until  its  repair  is  complete.  A  well- 
fitting  shoe  should  be  worn,  and  methodical  massage  and  stretching 
of  the  tissues  should  be  continued  as  long  as  the  tendency  to 
deformity  remains. 

By  this  treatment  the  symptoms  may  be  relieved,  and  in 
many  instances  a  return  to  the  normal  shape  and  function  can 
be  assured. 

'  New  York  Medical  Journal,  March  5,  1887. 


704  ORTHOPEDIC  S UB GEB  Y. 

Weakness  of  the  Anterior  Metatarsal  Arch. 

Anterior  Metatarsalgia  and  Morton's  Neuralgia.  A  pecu- 
liar spasmodic  pain  about  the  fourth  toe  was  described  by  Morton, 
of  Philadelphia,  long  before  its  predisposing  and  exciting  causes 
were  understood.  For  this  reason  a  description  of  the  symptoms 
may  with  advantage  precede  a  consideration  of  the  weakness  of 
which  they  are  usually  the  result. 

Typical  cases  of  Morton's^  painful  affection  of  the  foot  are 
characterized  by  a  sudden  cramp-like  pain  in  the  region  of  the 
fourth  metatarsophalangeal  articulation. 

The  pain  may  begin  as  a  burning  sensation  beneath  the  toe,  as 
a  numb  or  tingling  feeling,  as  a  sudden  cramp,  or  as  a  peculiar 
feeling  of  discomfort  about  the  articulation  that  increases  in 
severity  until  it  becomes  almost  unbearable.  At  first  the  pain  is 
confined  to  the  neighborhood  of  the  affected  joint,  but  unless  it 
is  relieved  it  radiates  to  the  extremity  of  the  toe,  to  the  dorsum 
of  the  foot,  or  up  the  leg.  In  many  instances  the  onset  of  the 
pain  is  preceded  by  the  sensation  of  something  moving  or  slipping 
in  the  foot ;  in  some  cases  the  pain  may  be  induced  by  sudden 
movements,  missteps,  or  long  standing,  and  in  practically  all 
the  cases  the  pain  is  felt  only  when  the  shoes  are  worn.  The 
frequency  of  the  recurrent  cramp  varies  ;  in  some  cases  it  is  felt 
only  at  infrequent  intervals  ;  in  others  it  practically  disables  the 
patient.  When  the  cramp  habit  has  been  acquired,  very  slight 
causes  may  induce  the  pain,  for  example,  a  thin-soled  shoe,  a  hot 
pavement,  "  the  sticking  of  the  sock  to  the  foot,"  and  the  like, 
but,  as  has  been  stated,  except  in  the  very  advanced  and  chronic 
cases,  the  pain  is  never  felt  except  when  the  shoe  is  worn. 

To  relieve  the  pain  the  patient  removes  the  shoe,  rubs  and 
compresses  the  front  of  the  foot,  flexes  and  extends  the  toes,  and 
the  like.  After  the  cramp  is  relieved  a  sensation  of  soreness 
remains,  and  occasionally  slight  swelling  may  appear,  but  in 
most  instances  there  are  no  external  signs,  although  the  affected 
articulation  is  usually  sensitive  to  deep  pressure  at  all  times. 

The  more  distinctive  term,  anterior  metatarsalgia,  a  term  sug- 
gested by  Poulosson,  of  Lyons,  in  1889,  may  be  employed  to 
include  Morton's  neuralgia,  and  similar  symptoms  of  pain  and 
discomfort  about  the  anterior  metatarsal  arch.  For  in  many 
instances  the  cramp-like  pain   is   referred  to  other  points,   for 

1  T.  G.  Morton.    American  Journal  of  the  Medical  Sciences,  August,  1876. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      705 

example,  to  several  adjoining  joints,  or  the  discomfort  caused 
apparently  by  direct  pressure  on  the  bones  of  the  weakened  arch 
may  be  more  troublesome  than  the  irregular  attacks  of  neuralgic 
pain. 

Etiology  and  Pathology.  In  78  cases  of  anterior  meta- 
tarsalgia  in  which  the  location  of  the  pain  was  noted,  it  was 
referred  to  the  fourth  metatarsophalangeal  articulation  in  60 ;  to 
the  third  and  fourth  articulation  in  6  ;  to  the  second,  third,  and 
fourth  in  6,  and  in  but  6  was  the  fourth  articulation  free  from 
pain.  The  pain  is  most  often  unilateral,  or,  if  the  second  foot  is 
affected,  it  is  usually  after  a  considerable  interval. 

The  affection  is  more  common  in  females  than  in  males.  Of 
84  cases  64  were  in  women  and  20  were  in  men. 

Anterior  metatarsalgia  is  not  an  affection  of  early  life,  the 
average  age  in  the  reported  cases  being  more  than  thirty  years. 
It  is  relatively  more  frequent  in  private  than  in  hospital  practice, 
and  not  infrequently  the  patients  are  of  a  distinctly  nervous 
type.  In  many  instances  it  is  supposed  to  be  a  family  inherit- 
ance. The  affection  is  usually  extremely  chronic.  Occasionally 
the  symptoms  may  cease  spontaneously,  and  in  such  instances  a 
particular  pattern  of  shoe  usually  receives  the  credit  of  the  cure. 

Morton  considered  the  affection  to  be  a  painful  affection  of  the 
plantar  nerves  due  to  compression  or  pinching  by  the  adjoining 
fourth  and  fifth  metatarsophalangeal  articulations.  This  compres- 
sion was  explained  by  the  anatomical  construction  of  the  foot — 
i.  e.,  the  mobility  of  the  fifth  metatarsal  bone  which  allowed  it 
to  roll  above  and  under  the  fourth,  its  relative  shortness  which 
allowed  the  head  and  base  of  the  adjoining  phalanx  to  be  brought 
against  the  adjoining  head  and  neck  of  the  fourth  bone,  and, 
finally,  by  the  peculiar  distribution  of  the  external  plantar  nerve 
between  these  bones  that  made  it  or  its  fibres  more  liable  to 
injury.  This  natural  mobility  and  thus  the  predisposition  to 
compression  might  be  exaggerated  by  a  sprain,  or  possibly  by 
rupture  of  the  transverse  metatarsal  ligament,  or  the  pain  might 
be  induced  by  wearing  tight  shoes,  but  in  many  instances  no 
cause  could  be  assigned.  On  this  theory  Morton  advocated 
excision  of  the  head  of  the  fourth  metatarsal  bone  to  remove  the 
point  of  counter-pressure.  This  operation  has  been  performed 
many  times,  but  practically  no  pathological  changes  in  the  re- 
sected bone  or  in  the  surrounding  parts  have  ever  been  discovered. 

In  more  recent  years  the  true  significance  of  Morton's  neuralgia 
and  of  similar  pains  in  the  front  of  the  foot  has  been  made  more 

45 


706  OB THOPEDIC  S  UB GEB  Y. 

clear  by  the  study  of  the  relation  of  weakness  of  the  anterior 
transverse  metatarsal  arch  to  the  symptoms.  Attention  was 
first  called  to  this  point  by  Poulosson,  of  Lyons,  and  again  by 
Roughton,  Woodruff,  and  others,  and  in  a  much  more  thorough 
and  convincing  manner  by  Goldthwait,^  of  Boston,  in  1894. 

The  Anterior  Metatarsal  Arch.  If  one  examines  a  normal 
foot  one  notices  that  the  two  middle  metatarsal  bones,  the  second 
and  third,  are  slightly  longer  and  on  a  higher  plane  than  their 
fellows.  On  the  sole  of  the  foot  the  arch  is  shown  by  the  depres- 
sion immediately  to  the  outer  side  of  the  muscular  projection 
of  the  great  toe-joint.  When  weight  is  borne  all  the  metatarsal 
bones  are  on  the  same  plane  and  the  arch  is  obliterated,  but  when 
the  weight  is  removed  the  arch  reforms  with  a  certain  natural 
resiliency.  In  walking  and  standing  the  weight  is  balanced  on 
the  head  of  the  third  metatarsal  bone,  as  shown  by  a  thickening 
of  the  skin  beneath  its  head,  but  the  strain  on  the  metatarsal 
arch  is  relieved  somewhat  by  the  balancing  action  of  the  muscles 
about  the  first  and  fifth  metatarsal  bones,  the  inner  and  outer 
supports  of  the  arch,  and  by  the  active  assistance  of  the  toes 
themselves.  When  the  arch  is  weak  or  broken  down  this  natural 
resilieucy  is  lost,  and,  in  some  instances,  the  centre  of  the  fore- 
foot is  not  only  depressed  but  it  is  iixed  in  this  abnormal  attitude. 

In  the  ordinary  type  of  depressed  anterior  arch  the  deformity 
may  be  shown  by  an  imprint  of  the  foot,  in  which  the  flabby 
tissues  of  the  depressed  arch  encroach  upon  the  clear  space  repre- 
senting the  longitudinal  arch,  and  obliterate  what  Goldthwait 
calls  the  re-entering  angle  to  the  outer  side  of  the  great  toe-joint, 
which  in  the  normal  foot  indicates  the  highest  point  of  the  meta- 
tarsal arch.  In  many  instances,  however,  the  imprint  of  the 
foot  subject  to  Morton's  neuralgia  may  be,  to  all  intents,  normal, 
and,  on  the  other  hand,  depression  of  the  metatarsal  arch,  one  of 
the  very  common  results  of  improper  shoes,  may  be  present,  yet 
unaccompanied  by  pain  or  discomfort. 

Depression  of  the  anterior  arch,  the  result  of  the  loss  of  the 
activity  of  the  accessory  supports  of  the  arch,  predisposes  to  pain 
because  of  abnormal  pressure  upon  the  persistently  depressed 
articulations  from  beneath,  and  it  predisposes  to  pain,  as  the 
writer  has  endeavored^  to  explain,  because  the  metatarsophalangeal 
joints  of  an  arch,  that  is  habitually  depressed,  are  exposed  to 
the  direct  lateral  compression  of  a  narrow  or  ill-shaped  shoe. 

■•  Boston  Medical  and  Surgical  Journal,  vol.  cxxxi.  p.  233. 
2  New  York  Medical  Record,  August  6,  1898. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      707 

This  point  may  be  illustrated  in  the  hand.  When  lateral 
pressure  is  applied,  the  hand  is  folded  together  and  the  anterior 
metacarpal  arch  is  increased  in  depth,  but  if  the  fingers  are  dorsi- 
flexed  so  that  it  is  fixed  in  a  depressed  position,  then  lateral 
compression  causes  great  pain  at  all  the  articulations  (Fig.  420) ; 
or  if  one  finger  is  dorsifiexed  and  the  corresponding  metacarpal 
bone  is  thus  forced  below  the  level  of  its  fellows,  lateral  compres- 
sion causes  pain  at  the  compressed  joint.  Or  if  the  metacarpal 
bone  of  the  little  finger  is  made  to  override  the  fourth,  lateral 
pressure  causes  pain  usually  of  a  more  acute  character  than  at 
the  other  joints,  because  the  opportunity  for  direct  pressure  is 
more  favorable.^     Finally,  if  firm  pressure  is  made  upon  one  or 

Fig.  420. 


Position  of  the  fingers  corresponding  to  dorsiflexion  of  the  toes,  an  attitude  in  which 
lateral  pressure  causes  pain. 

the  other  side  of  the  head  of  the  depressed  metacarpal  bone  of  the 
dorsifiexed  finger  in  the  palm  of  the  hand,  a  point  of  sensitive- 
ness, representing  apparently  the  digital  nerve,  can  be  made  out. 
The  same  experiments  may  be  tried  upon  the  foot  with  the  same 
results,  and  it  would  seem  to  make  clear  the  mechanism  of  the 
pain  of  Morton's  neuralgia  and  the  allied  forms  of  discomfort  at 
the  front  of  the  foot. 

Anterior  metatarsalgia  is  in  most  instances  the  result  of  weak- 
ness or  depression  of  the  anterior  metatarsal  arch  as  a  whole  or  in 
part,  and  the  quality  of  the  pain  corresponds  fairly  to  the  form 
of  weakness  or  deformity.  If,  for  example,  the  entire  arch  is 
rigidly  depressed,  as  in    certain    rheumatic    affections,  the    dis- 

'  ThiH  anatomical  X'sculiarity  is  well  known  to  school-boys. 


708  ORTHOPEDIC  SURGERY. 

comfort  is  likely  to  be  caused,  in  great  degree,  by  the  direct 
pressure  of  the  sensitive  depressed  metatarsophalangeal  joints 
on  the  sole  of  the  shoe ;  or,  if  lateral  pressure  is  exerted  as 
well,  the  discomfort  or  pain  may  be  referred  to  the  metatarsal 
arch  in  general.  If  the  metatarsal  arch  is  weakened,  depressed, 
and  broadened,  but  not  rigid,  the  discomfort  is  often  referred, 
as  in  the  preceding  instance,  to  the  centre  of  the  arch,  and  this 
discomfort  is  increased,  in  some  instances,  by  a  painful  callus 
representing  abnormal  pressure  at  this  point.  If  one  of  the 
metatarsal  bones  falls  below  its  fellows,  the  lateral  pressure  of 
a  narrow  shoe  may  cause  neuralgic  pain  at  this  joint,  but  in 
many  cases  in  which  the  anterior  arch  is  depressed  the  patient 
makes  but  little  complaint  of  pain.  In  certain  instances,  more 
particularly  those  of  Morton's  typical  neuralgia,  the  foot  may 
appear  to  all  intents  normal ;  in  such  cases  it  may  be  inferred 
that  the  sharp  and  characteristic  pain  is  caused  by  pressure 
applied  to  the  overriding  fifth  metatarsal  bone,  just  as  similar  pain 
is  felt  if  the  hand  is  suddenly  compressed  while  the  fifth  meta- 
carpal bone  is  in  the  same  position.  This  theory  is  the  more 
probable  when  one  considers  the  symptoms ;  for  example,  the 
sensation  of  something  slipping  or  moving,  the  necessity  for  the 
removal  of  the  shoe  to  flex  and  extend  the  toes  and  to  compress 
the  foot,  apparently  with  the  instinctive  aim  of  replacing  a 
depressed  arch,  or  a  misplaced  bone  in  the  arch.  It  would  also 
explain  how  the  shoe  may  be  the  most  direct  of  the  exciting  causes 
of  the  deformity,  in  that  it  compresses  the  forefoot  and  throws 
more  weight  upon  it  by  elevating  the  heel.  If  the  arch  is  depressed 
or  becomes  depressed,  or  if  a  bone  in  the  arch  overrides  another, 
this  compression  causes  the  symptoms. 

That  classical  Morton's  neuralgia  is  but  one  expression  of 
weakness  of  the  anterior  arch  of  the  foot  is  illustrated  by  an 
analysis  of  30  cases  seen  recently  in  private  practice : 


The  pain  was  referred  to  the  fourth  toe  in 12 

"  "  "      third  and  fourth  toes  in 4 

"  "  "      second,  third,  and  fourth  toes  in  .        .        .2 

"  "  "      third  toe  in 3 

"  "  "      second  and  third  toes  in         ....    2 

"  "  "      second  toe  in 6 

"  "  "      to  all  the  toes  in 1 

The  right  foot  was  involved  in 13 

The  left  "  "  7 

Both  feet  were  affected  in 8 

Twenty-four  of  the  patients  were  females  ;  four  were  males. 

The  Influence  of  the  Shoe  in  Causing  Disability  and  Pain. 
In  the  etiology  of  pain  and  discomfort  about  the  anterior  arch 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     709 

one  must  recognize  the  shoe  not  only  as  the  direct  cause  of  the 
pain,  but  also  as  the  most  important  of  the  predisposing  causes  of 
weakness  of  the  anterior  arch,  of  which  the  pain  is  a  symptom, 
since  it  compresses  the  toes,  lifts  them  off  the  ground  by  its 
"  rocker  sole,"  and  thus,  by  preventing  their  normal  function, 
throws  additional  strain  and  pressure  upon  the  arch.  In  fact,  in 
a  very  large  proportion  of  feet  that  are  supposed  to  be  normal  in 
appearance  and  functional  ability,  the  toes  are  habitually  dorsi- 
flexed  in  a  claw-like  attitude,  that  shows  entire  disuse  of  their 
function  both  as  to  support  and  progression.  Women  wear  shoes 
with  narrower  soles  and  higher  heels  than  men,  and  this  seems 
the  most  reasonable  explanation  of  the  fact  that  they  are  more 
subject  to  the  affection. 

The  shoe  also  predisposes  to  habitual  elevation  of  the  fifth 
metatarsal  bone,  because  this  bone  almost  invariably  overhangs 
the  narrow  sole.  The  fourth  metatarsal  bone  becomes,  therefore, 
the  outer  support  of  the  arch,  and  is  almost  always  found  to  be 
on  a  lower  level  than  the  adjoining  bones.  This  relation,  together 
with  a  laxity  of  muscular  and  ligamentous  support  induced  by 
injury  or  otherwise,  may  account  for  the  location  of  the  pain  at 
this  point  in  the  majority  of  cases.  Although  in  certain  instances 
a  neuritis  may  follow  direct  injury,  yet  this  assumption  is  not  at 
all  necessary  to  explain  the  symptoms.  Nor  is  it  likely  that  the 
peculiar  distribution  of  the  nerves  at  this  point  has  any  direct 
influence  on  the  pain,  for  the  nerve  supply  of  all  the  joints  and 
all  the  toes  is  practically  identical. 

Other  Factors  in  the  Etiology.  Besides  the  general  effect  of  the 
shoe,  and  the  possible  influence  of  an  inherited  predisposition  to  the 
affection,  which  seems  evident  in  certain  cases,  or  of  weakness  or 
direct  injury  of  the  anterior  arch,  one  recognizes  among  the 
causes  or  complications  of  anterior  metatarsalgia  weakness  of  the 
longitudinal  arch,  or  flat-foot,  which  may  be  combined  with  a 
depression  of  the  anterior  arch.  Less  often  the  longitudinal 
arch  may  be  exaggerated  in  depth  and  the  dorsal  flexion  of  the 
foot  may  be  limited  by  a  shortened  tendo  Achillis ;  thus  more 
pressure  is  brought  upon  the  front  of  the  foot.  In  these  cases 
the  pain  may  be  increased  by  corns  or  calloused  skin  beneath  the 
.depressed  bones,  and  in  many  instances  the  discomfort  of  the 
depressed  arch  of  the  ordinary  type  is,  in  great  part,  caused  by 
a  sensitive  corn  or  fibroma  at  the  point  of  greatest  depression, 
and  the  patient  may  be  entirely  relieved  by  its  removal.  (See 
Contracted  Foot.) 


710 


ORTHOPEDIC  SURGERY. 


Fig.  421. 


Although  the  symptoms  of  anterior  metatarsalgia  may  be 
explained  in  most  instances  by  the  primary  effect  of  improper 
shoes,  by  weakness  and  abnormality  of  the  foot  itself,  and  by  the 
local  sensitiveness  of  the  parts  that  are  continually  subjected  to 
strain,  pressure,  and  injury,  yet  in  some  instances  the  symptoms 
can  be  accounted  for  only  by  local  neuritis ;  in  others  they  are 
aggravated  by  gout  or  rheumatism  or  general  debility,  and,  as 
has  been  mentioned  in  a  large  proportion  of  the  cases,  the  patients 
are  of  a  distinctly  nervous  type. 

It  may  be  stated,  in  conclusion,  that  anterior  metatarsalgia  in 
its  milder  forms  is  a  very  common  affection,  and  one  rarely  treats 
a  patient  who  does  not  know  of  other  cases  similar  to  his  own. 

Treatment.  The  most  important  local  treatment  is  to  provide 
the  patient  with  a  proper  shoe.  This  shoe  must  be  of  proper 
shape  with  a  thick  sole,  so  broad  that  no 
lateral  compression  of  the  toes  is  possible, 
with  a  high  arch,  as  suggested  by  Gibney, 
in  order  to  remove  a  part  of  the  pressure 
from  the  heads  of  the  metatarsal  bones,  and 
a  low  heel. 

As  an  immediate  treatment  a  firm  band- 
age about  the  metatarsal  region,  as  suggested 
by  Morton,  may  aid  in  supporting  the  meta- 
tarsal arch,  or,  better,  adhesive  plaster 
strapping  may  be  applied  about  the  entire 
metatarsus,  with  the  object  of  compressing 
the  foot  somewhat  as  a  tight  glove  com- 
presses the  hand.  Beneath  or  slightly  be- 
hind the  affected  joint  or  the  depressed  arch, 
a  pad,  preferably  an  oval  piece  of  sole- 
leather,  about  one  inch  by  three-quarters  of 
an  inch  in  size  and  one-quarter  in  thick- 


A  brace  for  anterior  meta- 
tarsalgia. A  indicates  a 
point  beneath  the  fourth 
metatarsophalangeal    artic-  •  i      i  n     i        i  i        />        t    ^ 

uiation,  which  is  elevated  ness  With  bevelled  edges,  may  be  faxed  to 
SeSd'arruSr'^  '"  the  solc  of  the  foot  with  adhesivc  plaster,  so 
that  depression  of  the  arch  or  overriding  of 
the  adjoining  bones  may  be  prevented.  This  pad,  suggested  by 
Poulosson  and  Goldthwait,  usually  relieves  the  pain,  and  when 
the  exact  place  has  been  ascertained  it  may  be  fixed  to  the  sole 
of  the  shoe. 

As  a  rule,  however,  a  metal  support  will  be  found  to  be  more 
comfortable  and  far  more  efficient.  This  may  be  constructed  of 
light  steel  (19  gauge)  upon  a  plaster  cast  of  the  sole  of  the  foot, 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      711 

of  which  the  natural  depressions,  indicating  the  anterior  and  the 
longitudinal  arches,  have  been  somewhat  exaggerated.  The 
anterior  extremity  of  the  brace  is  made  as  wide  as  the  foot,  and 
extends  forward  slightly  beyond  the  metatarsophalangeal  articu- 
lations. The  brace  serves  to  support  the  anterior  as  well  as  the 
longitudinal  arch.  In  certain  instances  one  or  more  of  the  meta- 
tarsophalangeal articulations  may  be  sensitive  to  motion.  In 
such  cases  the  sole  plate  must  extend  from  the  heel  nearly  to  the 
extremities  of  the  toes  in  order  to  splint  the  foot  for  a  time.  If 
there  is  slight  depression  of  the  longitudinal  arch  it  may  be 
further  corrected  by  raising  the  inner  border  of  the  heel  and  sole 
of  the  shoe ;  but  if  it  is  more  pronounced  a  flat-foot  brace  (Fig. 
411)  may  be  employed,  whose  anterior  extremity  is  modified  to 
support  the  metatarsal  arch,  as  is  shown  in  Fig.  421.  If,  on  the 
other  hand,  the  arch  is  exaggerated  and  if  dorsal  flexion  is 
limited,  treatment  with  the  aim  of  relieving  this  deformity  will 
be  necessary,  as  described  under  "  contracted  foot."  When  the 
immediate  symptoms  of  pain  and  local  discomfort  have  been 
relieved,  the  patient  must  endeavor  to  strengthen  the  natural 
supports  of  the  arch  by  proper  functional  use  of  the  foot,  and  by 
regular  exercises  of  the  muscles,  more  especially  by  methodical 
forced  flexion  of  the  toes,  as  this  motion  elevates  the  anterior 
metatarsal  arch  (Fig.  422).  Massage  of  the  foot  and  forcible 
manipulation  of  the  toes  for  the  purpose  of  overcoming  restriction 
of  motion  are  of  special  value. 

If  the  anterior  arch  is  rigidly  depressed,  as  in  some  instances, 
its  flexibility  must  be  restored  by  manipulation  or  by  forcible 
correction  under  anaesthesia  before  a  brace  can  be  applied.  If 
the  symptoms  are  very  acute,  and  particularly  if  they  have 
followed  direct  injury,  the  parts  should  be  placed  at  rest  and  the 
anterior  arch  should  be  elevated  and  supported  by  a  properly 
applied  plaster  bandage. 

In  chronic  and  resistant  cases,  or  when  conservative  treatment 
cannot  be  applied,  resection  of  the  neck  and  head  of  the  meta- 
tarsal bone  at  the  seat  of  pain  may  be  performed  as  advocated  by 
Morton.  The  operation  is  very  simple.  An  incision  is  made 
over  the  dorsal  surface  of  the  joint,  and  the  bone  is  divided  by 
bone  forceps.  The  toe  is  not,  as  a  rule,  removed,  but  after  the 
operation  it  slowly  recedes  between  the  adjoining  metatarso- 
phalangeal joints,  causing  a  rather  noticeable  deformity.  The 
operation  is,  as  a  rule,  successful,  but  in  the  majority  of  cases  it 
is  unnecessary. 


712  ORTHOPEDIC  SUBGEBY. 

The  general  condition  of  the  patient  should,  of  course,  receive 
attention,  and  local  applications,  electricity,  and  the  like,  may 
be  of  benefit  in  special  cases. 

A  sensitive  callus  beneath  the  arch  may  require  treatment,  and 
in  certain  cases  its  removal  may  be  the  only  treatment  required 
other  than  an  improved  shoe.  But,  as  a  rule,  the  cause  of  the 
callus  is  habitual  depression  of  one  or  more  of  the  metatarso- 
phalangeal articulations,  so  that  cure  can  only  be  assured  by 
supporting  the  arch  and  by  strengthening  its  natural  supports  in 
the  manner  already  described. 

Woodruff'  described  a  case  of  what  he  called  "  incomplete  luxa- 
tion of  the  metatarsophalangeal  articulation,"  in  which  the 
symptoms,  practically  identical  with  those  of  Morton's  neuralgia. 

Fig.  422. 


Exercise  for  the  weakened  metatarsal  arch. 

are  ascribed  to  an  upward  displacement  of  the  proximal  phalanx 
at  the  fourth  metatarsophalangeal  joint 

It  may  be  stated  in  this  connection  that  in  the  ordinary  forms  of 
metatarsalgia  patients  often  refer  the  pain  and  local  sensitiveness 
to  the  anterior  extremity  of  the  metatarsal  bone  rather  than  to  its 
lateral  aspect.  Persistent  dorsal  flexion  of  the  toes  that  is  so 
commonly  associated  with  depression  of  the  arch  may  strain  the 
capsular  ligament,  and,  subjecting  this  portion  of  the  joint  to 
abnormal  pressure,  may  explain  the  location  of  the  pain.  But 
except  in  extreme  cases  it  can  hardly  be  classed  as  a  subluxation. 

Another  writer,  Guthrie,^  described  a  case  in  which  intense 
pain  followed  overextension  of  the  third  phalanx  upon  the  second. 
Such  cases  are  extremely  uncommon,  and  need  only  be  mentioned. 

1  New  York  Medical  Record,  January  18, 1887.  ^  Lancet,  March  19, 1892. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      713 

Achillobursitis. 

Synonyms.  Achillodynia,  achillobursitis  anterior,  retro-cal- 
caneobursitis. 

Uoder  the  title  of  Achillodynia,  Albert,^  of  Vienna,  in  1893, 
called  particular  attention  to  an  affection  characterized  by  pain  and 
sensitiveness  about  the  insertion  of  the  tendo  Achillis,  symptoms 
usually  caused  by  irritation  or  inflammation  of  the  small  bursa 
lying  betAveen  the  insertion  of  the  tendon  and  the  bone  (Fig.  423). 

Etiology.  In  the  acute  cases  the  cause  of  the  bursitis  often 
appears  to  be  a  strain  of  the  tendon  or  direct  injury,  as  the 
symptoms  appear  immediately  after  running  or  jumping  or  after 
a  fall,  sometimes  after  a  long  walk  or  bicycle  ride. 

In  the  subacute  cases  the  symptoms  may  begin  almost  imper- 
ceptibly, so  that  it  may  be  impossible  to  assign  a  direct  cause 
other  than  the  pressure  of  the  shoe,  aggravated,  it  may  be,  by  an 
exostosis  of  the  os  calcis  beneath  the  insertion  of  the  tendon  or 
by  concretions  within  the  bursa.  In  many 
instances  rheumatism,  gout,  gonorrhoea,  or  ^^^'  '^'^^^ 

one  of  the  infectious  diseases  appear  to  be 
associated,  directly  or  indirectly,  with  the 
onset  of  the  symptoms,  or  the  bursa  may  be 
secondarily  involved  in  tuberculous  disease 
of  the  OS  calcis. 

Symptoms.  In  a  typical  case  pain  is  felt 
in  the  back  of  the  heel  at  the  insertion  of 
the  tendon  ;  the  pain  is  increased  by  use  of 
the  foot,  and  particularly  by  the  attitudes 
in  which  the  strain  on  the  part  is  increased, 
as,  for  example,  in  descendino;  stairs.    There     .^"^ff  ^^*^it^  ^^®  *®°,*^? 

^    -'  ^      '  °  Achillis  and  the  os  calcis. 

is  also  sensitiveness  to  pressure  about  the 

back  of  the  heel  on  either  side  of  the  insertion  of  the  tendon. 

In  most  cases  a  slight  swelling,  often  more  prominent  on  the  inner 

than  the  outer  side  of  the  tendon,  indicates  the  situation  of  the 

bursa. 

In  the  chronic  cases  the  enlargement  of  the  bursa  is  very 
noticeable,  and,  in  addition,  the  entire  posterior  aspect  of  the  heel 
often  appears  to  be  thickened.  This  is  due  probably  to  the 
secondary  irritation  about  the  fibrous  expansion  of  the  tendon 
and  the  adjoining  periosteum.      In  many  cases  the  symptoms  are 

1  Wiener  ined.  I'resse,  January  8, 1893. 


714  ORTHOPEDIC  SURGERY. 

pronounced ;  pain  is  often  felt  in  the  bottom  of  the  heel  or  it 
radiates  up  the  back  of  the  leg.  The  patient,  unable  to  use  the 
power  of  the  calf  muscle,  everts  the  foot  in  walking,  thus  snbject- 
ing  the  arch  to  overstrain,  so  that  the  symptoms  of  the  weak  foot 
are  often  added  to  those  of  the  original  trouble.  Not  infre- 
quently, however,  the  two  affections  may  be  associated  from  the  be- 
ginning in  one  or  the  other  foot.  The  patient  complains  much  of 
stiffness  and  weakness  at  the  ankle  and  subastragaloid  joints.  In 
the  acute  cases,  or  in  acute  exacerbations,  there  is  usually  burn- 
ing and  throbbing  pain  characteristic  of  acute  inflammation,  but 
in  the  subacute  form  the  pain  is  slight,  and  is  troublesome  only 
after  overexertion. 

Pathology.  The  pathological  changes  do  not  differ  from  those 
found  in  and  about  other  bursse  under  similar  conditions.  In 
the  mild  cases  the  lining  membrane  is  simply  congested,  and  the 
cavity  contains  serous  fluid.  In  the  chronic  cases  the  walls  are 
much  thickened,^  the  lining  membrane  is  fringed  and  redupli- 
cated ;  the  contents  are  semisolid,  and  sometimes  calcareous 
masses  are  present.  Similar  changes  are  found,  however,  in  the 
bursse  of  apparently  normal  subjects,  so  that  the  condition  of  the 
bursa  may  not  always  correspond  to  the  character  of  the  symp- 
toms. Suppuration  of  the  sac  occasionally  occurs,  and  it  may 
be  the  seat  of  tuberculous  or  syphilitic  disease.  In  cases  of  long 
standing  the  parts  adjoining  the  bursa,  the  expansion  of  the 
tendon,  and  the  periosteum  become  thickened,  so  that  the  bone 
appears  to  be  increased  in  breadth  and  may  actually  become  so. 

Treatment.  When  once  established  the  affection  is  usually 
of  a  very  chronic  nature,  as  is  explained  by  the  strain  to  which 
the  sensitive  part  is  subjected  by  the  use  of  the  foot.  It  is, 
therefore,  important  to  apply  efficient  treatment  at  the  beginning 
of  the  affection  if  an  opportunity  is  afforded.  Efficient  treatment 
implies  absolute  rest,  and  in  all  cases  of  any  severity,  particularly 
those  of  acute  onset,  a  well-fitting  plaster  bandage  should  be 
applied  to  hold  the  foot  slightly  inverted  and  at  a  right  angle  to 
the  leg.  This  should  be  worn  until  all  symptoms  have  subsided. 
In  very  mild  cases,  following  immediately  on  a  strain  or  overuse, 
simple  rest  with  the  application  of  heat,  massage,  and  pressure 
may  be  efficient.  And  in  the  subacute  cases  the  symptoms  may 
be  relieved  by  the  application  of  a  long,  broad  band  of  adhesive 
plaster,  from  the  toes  over  the  back  of    the  heel  to  the  upper 

1  Rijssler.    D.  Z.  f.  Chir.,  Bd.  Ixii.  H.  ]  and  3. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      715 

third  of  the  calf,  the  foot  being  slightly  plantar  flexed.  This  is 
firmly  fixed  by  narrow  strips  of  plaster  about  the  metatarsus, 
the  heel,  and  the  calf.  By  this  means  pressure  is  exerted  upon 
the  bursa,  and  much  of  the  strain  is  removed  from  the  tendon. 

In  persistent  cases  a  brace  may  be  used  with  advantage  for  the 
purpose  of  preventing  strain  upon  the  tendon.  Two  lateral 
uprights  with  a  calf  band  and  padded  strap  that  crosses  the  upper 
third  of  the  leg  are  attached  to  the  shoe,  provided  with  a  stop 
joint  at  the  ankle  as  used  in  the  treatment  of  paralytic  calcaneus  to 
prevent  dorsal  flexion.  (See  Talipes.)  As  the  patient  is  usually 
sensitive  to  jar,  the  heel  of  the  shoe  should  be  replaced  by  one 
of  thick  rubber.  In  connection  with  the  brace  the  stimulation 
of  the  cautery  and  the  pressure  of  the  adhesive  plaster  strapping 
seem  to  hasten  the  absorption  of  the  effusion  in  and  about  the 
bursa.  If  weakness  or  depression  of  the  arch  is  present,  as  a 
result  of  the  disability  or  combined  with  it,  a  foot  plate  should 
be  applied,  and  general  affections,  with  which  the  disability  is 
sometimes  associated,  should,  of  course,  receive  attention. 

Operative  Treatment.  In  persistent  cases,  in  which  the  symp- 
toms are  not  relieved  by  treatment,  the  enlarged  bursa  should  be 
removed  by  an  incision  on  the  inner  side  of  the  tendon,  as  the 
swelling  is  usually  most  prominent  here.  A  plaster  bandage  is 
then  applied  and  is  continued  until  the  symptoms  have  subsided. 
If  the  case  is  a  chronic  one,  it  may  be  advisable  to  divide  the 
tendo  Achillis  in  order  to  completely  remove  for  a  time  the  strain 
upon  the  sensitive  part.  In  any  case,  a  brace  of  the  character 
already  described  may  be  required  for  a  time  after  the  plaster 
support  has  been  removed.  Operative  treatment  is,  of  course, 
indicated  in  acute  suppurative  inflammation,  in  tuberculous  dis- 
ease, or  if  an  exostosis  beneath  the  bursa  or  concretions  within 
the  sac  are  present,  as  shown  by  an  X-ray  negative. 

Achillobursitis  Posterior. 

Tenderness,  pain,  and  swelling  at  the  back  of  the  heel  may 
be  due  to  inflammation  of  the  small  superficial  bursa  that  lies 
between  the  tendon  and  the  skin.  The  cause  is  usually  injury  or 
the  pressure  of  the  shoe.  The  symptoms  resemble  somewhat 
those  of  achillobursitis  anterior,  but  the  swelling  is  more  super- 
ficial, and  the  pain  is  caused  by  direct  pressure  rather  than  by 
tension  on  the  tendo  Achillis.  In  the  ordinary  case  removal  of 
the  pressure  will  at  once  relieve  the  symptoms,  but  if  the  discom- 


716  OB  THOPEDIC  S  UR  GEE  Y. 

fort  is  considerable  a  plaster  bandage  may  be  worn  for  a  week  or 
more. 

Sensitive  points  at  the  back  of  the  heel  are  usually  caused  by 
the  pressure  of  the  shoe.  In  rare  instances  prominent  points, 
or  exostoses  of  the  os  calcis  are  present,  that  may  require  special 
protection  or  removal. 

Strain  of  the  Tendo  Achillis. 

Not  infrequently,  and  usually  as  the  result  of  strain  or  overuse 
of  the  foot,  patients  complain  of  symptoms  similar  to  those  of 
achillobursitis,  but  on  examination  one  finds  that  the  pain  and 
sensitiveness  are  referred  to  the  tendon  itself.  There  is  no  swell- 
ing at  its  insertion,  or  pain  on  lateral  pressure  on  the  os  calcis. 
The  sensitive  area  may  be  as  high  up  as  the  junction  of  the 
tendon  with  the  muscle,  and,  again,  the  midpoint  of  the  tendon 
seems  most  painful. 

The  cause  in  some  cases  may  be  a  direct  strain  of  the  tendon 
or  of  the  muscular  fibres  near  its  origin,  or  inflammation  of  its 
fibrous  covering  due  probably  to  the  same  cause.  The  treatment 
is  similar  to  that  of  the  milder  type  of  achillobursitis,  by  the 
adhesive  plaster  strapping,  by  rest,  and,  later,  by  massage. 
Recovery  is  usually  rapid. 

Painful  Heel — Calcaneobursitis. 

Pain  referred  to  the  bottom  of  the  heel  and  sensitiveness  to 
pressure  on  standing  are  common  symptoms  of  the  weak  or  flat- 
foot.  Pain  at  this  point  may  be  one  of  the  symptoms  of  achillo- 
bursitis also.  In  rare  instances  the  painful  point  is  clearly 
localized,  and  is  confined  to  a  small  area  in  the  neighborhood  of 
the  inner  tuberosity  of  the  os  calcis.  The  cause  of  the  symptoms 
in  such  cases  may  be  an  inflamed  bursa  lying  between  the  perios- 
teum and  the  fatty  tissue  of  the  heel.  Such  bursee  may  contain 
hard  substances  or  even  a  fasciculated  neuroma.^ 

More  general  pain  and  tenderness  referred  to  the  heel  is  often 
caused  by  direct  pressure  and  bruising  of  the  tissues  by  overuse 
of  the  feet. 

Treatment.  Treatment  must  be  directed  to  the  condition  of 
which  the  pain  is  a  symptom,  and,  as  has  been  stated,  it  is  most 
often  one  of  the  symptoms  of  the  weak  or  broken-down  arch. 

1  Brousses  et  Berthier.    Revue  de  Chir.,  August,  1895. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      717 

If  the  tender  point  is  localized,  and  if  the  pain  is  increased  by- 
jars,  a  thick  rubber  heel  combined  with  an  inner  sole,  so  cut  out 
as  to  remove  the  direct  pressure  on  the  sensitive  point,  will  often 
relieve  the  symptoms.  In  persistent  cases,  in  which  the  sensitive 
point  is  distinctly  localized,  operative  intervention  for  the  removal 
of  the  bursa  is  indicated.  The  tissues  of  the  heel  may  be  turned 
forward  in  a  horseshoe-shaped  flap,  which  will  allow  a  thorough 
examination  of  the  affected  parts. ^ 

Sensitiveness  due  to  direct  contusion,  or  bruising  of  the  tissues 
caused  by  overuse,  must  be  treated  by  rest  and  by  change  of 
occupation,  unless  a  reduction  of  the  body  weight  or  improve- 
ment in  attitudes  relieve  the  symptoms. 

Plantar  Neuralgia. 

Synonym.     Plantalgia. 

Pain  referred  to  the  sole  of  the  foot  and  sensitiveness  to  pressure 
on  the  plantar  fascia  are  usually  symptomatic  of  the  contracted 
foot  (cavus) ;  less  often  such  symptoms  accompany  the  weak  or 
broken-down  arch. 

Pain,  tenderness,  and  thickening  of  the  fascia  sometimes  follow 
injury  (rupture  of  the  fascia),^  and  a  similar  condition  has  been 
described  by  Franke  as  one  of  the  sequelse  of  influenza.^ 

Treatment.  Pain  in  the  sole  of  the  foot,  symptomatic  of  the 
contracted  or  of  the  weak  foot,  may  be  relieved  by  the  treatment 
of  the  conditions  of  which  it  is  a  symptom.  In  the  rare  instances 
in  which  the  fascia  is  itself  injured  or  diseased,  local  rest,  as 
afforded  by  the  plaster  bandage,  is  indicated  until  the  acute 
symptoms  have  subsided. 

Ery  thromelalgia . 

Weir  Mitchell*  has  described  a  series  of  cases  characterized  by 
attacks  of  heat,  redness,  pain,  and  often  swelling  most  marked 
about  the  soles  of  the  feet.  Of  27  cases  all  but  2  were  in  women, 
many  of  whom  were  of  a  nervous  or  neurasthenic  type.  The 
affection  appears  to  be  a  form  of  vasomotor  disturbance.  Disturb- 
ances of  the  circulation  and  burning  pain  in  the  soles  of  the  feet 
are  common  symptoms  of  the  weak  foot  and  of  allied  affections, 

1  Duplay.    Clin.  Chir.  de  I'llfttel  Dieu,  S6rie  1897. 

2  Lerlerhose.    Verhaiul.  rler  Deut.  G.  f.  Chir.,  XXIII.  Kong.,  1894. 
■'  Archiv  f.  klin.  Chir.,  1895,  Bd.  xlix. 

*  Arnc-rican  Journal  oi  the  Medical  Sciences,  1878,  vol.  Ix.xvi. 


718 


ORTHOPEDIC  SURGERY. 


Fig.  424. 


but  in  such  cases  there  is  not  the  flushing  and  swelling  character- 
istic of  erythromelalgia.  In  this  affection  the  circulatory  disturb- 
ances are  not,  as  a  rule,  confined  to  the  feet,  but  are  seen  in  the 
legs  and  even  in  the  upper  extremities.^  It  deserves  mention  as 
a  possible  explanation  of  symptoms  in  obscure  cases.^ 

Hallux  Rigidus. 

Synonyms.     Hallux  flexus,  painful  great  toe. 
Hallux  rigidus  is  a  painful  affection  of  the  great  toe-joint, 
characterized  by  restriction  of  motion,  particularly  of  the  range 
of  dorsal  flexion.     In  advanced  cases  the  first  phalanx  may  be 
slightly  plantar  flexed  together  with   its  meta- 
tarsal bone ;  hence  the   name  hallux  flexus,  ap- 
plied by  Davies-Colley,  who  first  described  the 
affection. 

The  restriction  of  motion  may  be  complete,  as 
imjilied  by  the  term  rigidus  ;  the  joint  appears 
unduly  prominent  or  enlarged,  usually  slightly 
congested,  and  pressure  or  forced  movement 
causes  pain. 

The  symptoms  of  which  the  patient  complains 
are  a  burning  or  throbbing  pain  in  the  joint,  in- 
creased by  standing,  and  particularly  by  walking, 
because  of  the  enforced  movement  of  the  stiff 
and  painful  articulation.  There  are  many  cases 
in  which  there  is  no  actual  deformity  of  the 
joint  or  other  noticeable  change  ;  the  restriction 
of  motion  is  much  less,  and  the  symptoms  are  correspondingly 
slight. 

Etiology.  Typical  hallux  rigidus  is  most  common  in  adoles- 
cence, and  it  is  very  often  associated  with  the  weak  or  broken- 
down  foot.  In  such  cases  the  toe  is  crowded  into  the  narrow 
part  of  the  shoe,  and  is  thus  subjected  to  lateral  and  to  longi- 
tudinal pressure  as  well  as  to  the  additional  strain  that  the 
attitude,  characteristic  of  the  weak  foot,  throws  upon  it.  In 
some  cases  the  habitual  plantar  flexion  of  the  toe  may  be  the 
result  of  an  instinctive  effort  to  support  the  weak  arch  (hammer- 
toe flat-foot — Nicoladoni).  In  other  instances  hallux  rigidus  is 
caused  directly  by  traumatism  ;  as  by  stubbing  the  toe,  by  kicking 


The  dotted  outline 
shows  the  shape  of 
the  steel  splint  that 
may  be  inserted  in 
the  sole  of  the  shoe 
for  hallux  rigidus. 


1  Kahane.     Klin,  therap.  Wochen.,  May  20, 1900. 

-  Prentiss.    Transactions  of  the  Association  of  American  Physicians,  1897,  vol.  xii.  p.  303. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     719 

a  hard  object,  or  by  other  form  of  strain  or  injury.  The  affection 
appears  to  be,  primarily,  a  form  of  periarthritis,  caused  by  injury 
or  pressure.  The  restriction  of  motion  is  in  part  due  to  muscular 
spasm,  and  in  part  to  the  irritative  and  accommodative  changes 
in  the  ligaments  and  tendons.  In  more  advanced  cases  changes 
in  the  cartilage  and  shape  of  the  articulating  surfaces,  due  to 
disuse  of  function  and  to  pressure    and  friction,  may  be  present. 

Treatment.  If  the  rigid  and  painful  joint  is  not  associated 
with  a  weak  arch,  it  may  be  relieved  by  providing  the  patient 
with  a  proper  shoe  which  exerts  no  pressure  on  the  sensitive  part. 
Motion  of  the  joint  may  be  lessened  by  increasing  the  thickness 
of  the  sole,  or,  if  necessary,  it  may  be  entirely  restricted  by  the 
insertion  of  a  brace  of  tempered  steel  between  the  two  layers  of 
the  sole,  as  shown  in  the  diagram.  If,  as  in  some  instances,  the 
flexed  and  painful  toe  is  associated  with  rigid  flat-foot,  both 
deformities  may  be  overcorrected,  under  anaesthesia,  and  retained 
in  proper  position  by  a  plaster  bandage,  as  a  preliminary  treat- 
ment. 

If  the  milder  type  of  painful  joint  is  associated  with  the  ordi- 
nary weak  foot,  the  treatment  of  the  latter  condition  will  usually 
relieve  the  symptoms.  In  this  class,  particularly  among  the 
poorer  patients,  the  shoe  may  be  raised  on  the  inner  side  and 
the  sole  stiffened  by  means  of  the  wedge-shaped  sole,  as  already 
described  in  the  treatment  of  the  weak  and  flat-foot.  If  painful 
motion  is  restricted  and  the  exciting  causes  of  the  disability  are 
removed,  relief  of  the  symptoms  is  usually  immediate.  In  the 
chronic  cases,  in  which  the  pathological  changes  are  more  ad- 
vanced, excision  of  the  joint  may  be  necessary. 

Painful  Great  Toe-joint  in  Older  Subjects. 

A  similar  condition  of  the  joint  is  sometimes  found  in  older 
subjects.  In  many  instances  the  foot  is  well  formed,  and  the 
restriction  of  motion  in  the  joint  is  very  slight ;  yet  forced  dorsal 
flexion  causes  pain,  and  long  standing  or  walking  induces  dis- 
comfort, particularly  a  dull  ache  in  the  joint  and  sharp  neuralgic 
pain  referred  to  the  terminal  phalanx.  In  some  cases  the  onset 
of  the  symptoms  may  be  ascribed  to  a  long  walk  or  "  mountain 
climb,"  in  others  to  wearing  tight  shoes,  and  in  some  instances 
no  definite  cause  can  be  assigned  by  the  patient.  In  cases  of 
this  type  the  symptoms  are  often  supposed  to  be  evidences 
of  gout  or  rheumatism.     Admitting  that  in  certain  instances  the 


720 


ORTHOPEDIC  SURGERY. 


discomfort  may  be  aggravated  by  a  constitutional  disease,  still  no 
relief  can  be  obtained  by  medication  unless  it  is  combined  with 
the  local  treatment  that  has  been  described  in  the  preceding  sec- 
tion. The  relief  afforded  by  such  treatment  alone  proves,  in 
many  instances,  that  the  affection  is  purely  local  in  its  character 
(Fig.  424). 

As  has  been  mentioned,  pain  referred  to  this  joint  is  a  common 
symptom  of  the  weak  foot  and  of  the  contracted  foot  as  well.  It 
is  also  caused  by  simple  pressure  on  the  joint,  and  by  the  use  of 
improper  shoes  which  force  the  toes  into  the  abducted  position. 

In  rare  instances  pain  directly  beneath  the  great  toe  and  sensi- 
tiveness to  pressure  about  the  sesamoid  bones  seem  to  indicate  an 


Fig.  425. 


Simple  congenital  varus,  adduction  without  supination— a  form  of  pigeon-toe. 

inflammation  of  the  tendon  sheath  or  local  periarthritis.  If  the 
discomfort  is  persistent  the  sesamoid  bones  may  be  removed.  As 
a  rule,  such  symptoms  occur  only  in  combination  with  pain  or 
deformity  of  the  great  toe-joint. 

Hallux   Varus. 

Adduction  of  the  great  toe  is  not  infrequent  in  infancy,  and  it 
may  be  associated  with  a  slight  degree  of  varus  deformity  (Fig. 
425).  The  peculiarity  attracts  the  mother's  attention  because  of 
the  difficulty  of  drawing  on  the  socks.  In  many  instances  the 
muscles  seem  abnormally  developed,  and  the  toe  appears  to  be 
somewhat  prehensile  in  its  movements. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      721 


FrG.  426. 


Treatment.  The  abnormal  mobility  may  be  checked  by 
inclosing  the  toes  with  a  narrow  strip  of  adhesive  plaster ;  in  any 
event,  the  ordinary  shoe  may  be  depended  upon  to  correct  any 
residual  deformity  of  this  character.  If  the  adducted  toe  is  com- 
bined with  varus,  it  represents  a 
slight  degree  of  club-foot  that  must 
be  corrected  in  the  ordinary  manner. 
(See  Talipes.) 

Pigeon-toe. 

Congenital  hallux  varus  forms 
one  variety  of  what  is  known  as 
pigeon-toe,  or  the  habitual  turning 
in  of  the  feet  in  walking.  The  in- 
ward rotation  may  be  due  also  to 
bow-legs,  or  it  may  be  an  effect  of 
congenital  talipes  that  persists  after 
the  cure  of  the  deformity,  or  of  the 
exceptional  variety  of  coxa  vara  in 
which  the  depressed  necks  of  the 
femora  are  turned  forward.  In 
most  instances  pigeon-toe  in  child- 
hood is  symptomatic  of  weakness 
either  of  the  arch  of  the  foot  or  of 
the  knees  (genu  valgum).  In  such 
cases  it  is  a  conservative  effort  of 
nature  that  serves  to  check  further 
deformity,  and  it  needs  no  treat- 
ment other  than  that  which  may  be 
applied  to  the  weakness  of  which  it 
is  a  symptom. 

In  the  exceptional  cases,  in  which 
the  posture  is  not  symptomatic  of 
weakness  or  the  effect  of  deformity, 
the  sole  of  the  shoe  may  be  raised 

slightly  on  the  outer  border.  This  will  correct  the  attitude  in  the 
milder  type,  if  combined  with  instruction  and  training.  In  rare 
instances  the  in-toeing  seems  to  be  caused  by  limitation  of  the 
range  of  outward  rotation  at  the  hip-joints,  a  restriction  that  must 
be  overcome  by  systematic  stretching  of  the  contracted  parts.  In 
these  and  in  the  more  o})stinate  cases  of  the  simple  type  appa- 

46 


An  appliance  constructed  of  leather 
bands  and  elastic  webbing  for  ttie  cor- 
rection of  in-toeing.  Name  of  the  in- 
ventor unknown. 


722  ORTHOPEDIC  SUBGEBY. 

ratus  may  be  applied,  similar  to  that  used  in  the  after-treatment 
of  congenital  club-foot,  to  hold  the  feet  in  the  proper  attitude 
(Fig.  426).  It  must  be  borne  in  mind  that  the  proper  attitude 
of  the  feet  is  one  of  parallelism  not  of  outward  rotation,  and  that 
slight  pigeon-toe  will,  as  a  rule,  correct  itself  as  the  child  grows 
older. 

Hallux  Valgus. 

Hallux  valgus  is  a  deformity  in  which  the  great  toe  is  turned 
outward  to  an  exaggerated  degree.  Outward  deviation  of  the  toe 
is  so  common,  owing  to  the  use  of  improper  shoes,  that  it  is  not 
recognized  as  a  deformity,  at  least  from  the  popular  standpoint, 
unless  the  joint  appears  to  be  much  "  enlarged,"  forming  a  so-called 
bunion. 

Hallux  valgus  is  practically  a  partial  dislocation  of  the  phalanx 
upon  the  metatarsal  bone.  In  well-marked  cases  the  metatarsal 
bone  is  adducted  or  turned  inward,  so  that  an  abnormal  interval 
separates  its  head  from  its  fellows,  while  the  phalanx  is  displaced 
outward  and  articulates  only  with  the  outer  condyle.  The  angle 
thus  formed,  or,  more  properly,  the  inner  condyle  of  the  adducted 
metatarsal  bone,  makes  the  prominent  or  "  outgrown  "  joint  (Fig. 
435).  This  projects  sharply  beneath  the  skin,  and  is  exposed  to 
injury  and  to  the  pressure  of  the  shoe ;  thus  a  bursa  develops 
beneath  the  skin,  while  a  corn  or  callus  forms  on  its  superficial 
surface.  The  projecting  bone,  covered  by  the  irritated  bursa  and 
the  thickened  skin,  makes  up  the  bunion. 

In  many  instances  the  other  toes  are  displaced  outward,  in 
the  direction  corresponding  to  that  of  the  great  toe,  or  this  may 
be  rotated  on  its  long  axis  and  lie  above  or  beneath  its  fellows. 

Pathology.  The  pathological  changes  are  such  as  usually 
follow  deformity,  disuse  of  function,  and  injury.  The  cartilage 
on  the  exposed  condyle  atrophies,  the  sesamoid  bones,  together 
with  the  tendon,  are  displaced  outward,  the  tissues  on  the  outer 
side  undergo  accommodative  shortening,  while  those  on  the  inner 
side  are  correspondingly  lengthened  and  attenuated.  The  surface 
of  the  bone  beneath  the  irritated  periosteum  is  often  roughened 
and  irregular,  and  exostoses  may  form  about  the  condyle,  and 
thus  aggravate  the  effects  of  the  external  pressure. 

Etiology.  The  deformity  is  the  direct  effect  of  shoes  that  are 
too  narrow  and  of  improper  shape,  and  in  some  instances  too 
short  for  the  foot,  so  that  the  great  toe  is  subjected  to  lateral 
and  longitudinal  pressure.     The  deforming  effect  of  the  shoe  is 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     723 

increased  if  the  arch  is  weak,  so  that  the  toe  is  forced  forward 
into  the  narrower  part  of  the  shoe  when  the  foot  is  in  use.  The 
deformity  may  be  increased  by  injury  or  by  the  changes  that 
follow  gout,  rheumatism,  rheumatoid  arthritis  and  the  like,  and 
in  rare  instances  the  distortion  may  be  the  direct  result  of  such 
diseases  ;  but  all  other  factors  are  of  slight  importance  when 
compared  to  the  deforming  influence  of  the  ordinary  shoe.  The 
deformity  begins  at  a  very  early  age ;  it  advances  more  rapidly 
during  adolescence,  but  the  symptoms  do  not  often  become 
troublesome  until  later  years.  Both  toes  are  aifected,  as  a  rule, 
although  the  deformity  and  its  accompanying  symptoms  are 
usually  more  marked  on  one  side. 

Symptoms.  As  has  been  stated,  the  slighter  grades  of  defor- 
mity are  not  recognized  as  such,  and  it  is  usually  because  of  the 
pain  due  to  the  irritated  corn  or  bursa,  and  incidentally  because 
of  the  outgrown  joint,  that  the  patients  apply  for  treatment. 

Treatment.  The  symptoms  in  the  ordinary  cases  may  be 
relieved  by  providing  a  proper  shoe,  by  which  pressure  on  the 
joint  is  completely  removed  (Figs.  407  and  432).  The  sole 
should  be  strong,  and  it  should  be  slightly  thicker  along  the  inner 
side,  so  that  the  sensitive  joint  may  be  inclined  away  from  the 
upper  leather.  In  cases  in  which  the  deformity  is  not  far 
advanced  the  use  of  a  proper  shoe  that  allows  space  for  an 
improved  position  of  the  great  toe,  combined  with  methodical 
manual  correction  of  the  deformity  and  exercise  of  the  disused 
muscles,  while  the  toe  is  guided  in  the  proper  directions  by  the 
fingers,  will  relieve  the  symptoms  promptly  and  practically  cure 
the  deformity.  If  the  longitudinal  or  the  metatarsal  arches  are 
depressed  they  should  be  properly  supported  (Figs.  404  and  421). 

Several  forms  of  correcting  braces  have  been  devised  to  be 
worn  during  the  day,  a  digitated  stocking  and  special  shoe  being, 
of  course,  necessary. 

A  simple  device  for  holding  the  toe  in  an  improved  position 
is  the  Holden  toe-post,  recommended  by  Walsham  and  Hughes. 
This  is  a  thin  piece  of  metal  so  fixed  in  the  front  and  inner  side 
of  the  sole  of  the  shoe  that  it  separates  the  first  and  second  toes 
from  one  another  and  holds  the  former  in  an  improved  position. 
It,  of  course,  necessitates  a  special  shoe  and  a  special  shoemaker 
to  fit  it  in  its  proper  place. 

8am])son^  makes  the  toe-post  of  tin  and  places  it  in  a  card- 
board inner  sole,  as  illustrated  in  the  diagrams  (Figs.  427-430). 

1  Johns  Hopkins  Bulletin,  January,  1902. 


724 


OB THOPEDIC  SURGEB  Y. 


The  use  of  a  splint  at  night  is  also  of  some  service.  For  this 
purpose  a  piece  of  celluloid  about  one-eighth  inch  in  thickness,  one 
inch  in  width,  and  about  six  inches  in  length  may  be  used. 
This,  having  been  moulded  to  the  proper  contour  by  placing  it 


Fig.  427. 


^ 


If 


D 


Making  the  pattern  for  a  toe-post.  A  heavy  piece  of  paper  folded  once  along  the  line  A  B. 
A  D  jBand  B  C  Fare  cut  away,  leaving  the  tongue  A  D  C  B.  AD  should  equal  the  depth 
of  the  shoe  at  that  point,  and  A  B  should  be  as  wide  as  the  length  of  the  slit  in  the  card- 
hoard  inner  sole.  The  tongue  is  inserted  in  the  slit,  and  the  bases  folded  back  and  cut  away 
to  conform  to  the  front  of  the  inner  sole.  When  removed  and  straightened  out  this  forms 
the  pattern  in  Fig.  428. 

Fig.  428. 


JE 


D 


A 


E 


Z> 


H 

Pattern  of  paper  from  which  the  tin  is  cut.    The  edges  B  D  and  C  C  are  to  be  turned  in.    lln 
is  folded  along  the  dotted  lines  A  B—D  C  and  D  C  forming  the  toe-post  in  Fig.  429. 


Fig.  429. 


Shows  the  toe-post  ready  to  be  inserted  into  the  cardboard  inner  sole.  Rough  points  on 
the  upper  and  under  surfaces  of  the  base,  which  are  made  by  punching  holes  with  an  awl, 
hold  the  toe-post  to  both  the  inner  sole  of  the  shoe  and  the  cardboard  inner  sole. 


Fig.  430. 


Cardboard  inner  sole  with  toe-post  and  foot  adductor  attached.    (Sampson.) 

in  hot  water,  is  secured  by  tapes  to  the  inner  side  of  the  toe  and 
foot. 

It  may  be  stated  that  in  the  class  of  cases  that  can  be  suc- 
cessfully treated  by  mechanical  correction  few  patients  will  be 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      725 

found  who  are  sufficiently  interested  in  the  cure  of  the  deformity 
to  submit  to  the  slight  discomfort  that  the  wearing  of  even  a 
carefully  adjusted  brace  entails. 

Operative  Treatment.  In  cases  in  which  the  deformity  is  of 
long  standing,  and  in  which  the  projecting  condyle  or  the  exostoses 
make  protection  of  the  sensitive  joint  difficult,  an  operation  is 
indicated.  The  primary  object  of  the  operation  is  to  remove 
the  projecting  bone.  This  may  be  accomplished  by  a  slightly 
curved  incision  about  the  inner  aspect  of  the  condyle,  the  centre 
being  below  the  joint,  so  that  the  scar  will  not  be  subjected  to 
pressure.  The  flap  of  skin  is  raised,  the  periosteum  and  part  of 
the  capsule  are  lifted  from  the  bone,  and  the  entire  condyle  is 
removed  with  a  chisel,  so  that  the  surface  is  made  perfectly 
smooth.  Contracted  tissues  that  resist  a  corrected  position  of 
the  toe  are  stretched  or  divided,  and  the  wound  having  been 
closed  with  sutures  a  plaster  bandage  is  applied  about  the  foot 
and  toe.  This  may  be  worn  with  advantage  for  several  weeks. 
The  after-treatment  consists  in  the  use  of  a  proper  shoe  and  daily 
manual  adduction  of  the  toe,  in  order  to  retain  the  improved 
position. 

Cuneiform  osteotomy  of  the  metatarsal  bone  is  an  effective 
operation  if  the  base  of  the  wedge  includes  the  projecting  bone. 
Resection  of  the  head  of  the  metatarsal  bone  is  an  effective 
operation,  and  it  may  be  indicated  if  the  deformity  is  extreme. 

As  has  been  stated,  hallux  valgus  is  often  combined  with  the 
weak  or  broken-down  arch ;  in  such  cases  the  foot  must  be  sup- 
ported by  a  properly  fitted  brace.  This  is  of  special  importance 
after  treatment  by  operation. 

Bunion.  The  discomfort  of  hallux  valgus  is  caused  in  great 
part  by  the  irritated  bursa  and  the  overlying  corn.  These 
symptoms  may  be  relieved  by  rest  and  by  hot  applications. 
Afterward  the  callus  or  corn  may  be  removed,  and  the  sensitive 
bursa  may  be  protected  by  a  bunion  plaster.  Operative  treat- 
ment should  be  deferred  until  after  the  acute  symptoms  have 
subsided. 

Hammer-toe. 

Hammer-toe  is  a  contraction  of  one  of  the  toes,  usually  of  the 
second,  in  which  the  first  phalanx  is  dorsiflexed,  the  second 
plantar  flexed,  while  the  third  may  be  flexed  or  extended.  The 
contracted  toe  is  overla])ped  by  its  fellows;  its  projecting  dorsal 
surface  is  subjected  to  the  ])ressurc  of  the  upper  leather  of  the 
shoe,  and   the  terminal   phalanx,  forced  against  the  sole  of  the 


726  ORTHOPEDIC  SUBGEBY. 

shoe  and  compressed  by  the  adjoining  toes,  becomes  flattened 
into  a  club  or  hammer-like  form.  The  nail  is  distorted  and 
often  "  ingrown ;"  in  most  cases  a  corn  or  callus  forms  upon  the 
extremity  of  the  toe,  and  a  small  bursa  and  corn  over  the  pro- 
jecting knuckle  on  the  dorsal  surface.  A  third  corn  or  callus  is 
often  found  beneath  the  head  of  the  metatarsal  bone  which  has 
been  forced  downward  by  the  flexion  of  the  toe. 

Hammer-toe  is  usually  bilateral ;  it  may  be  congenital  and 
even  hereditary,  but  it  is  usually  acquired,  the  effect  of  shoes  that 
are  too  short  and  too  narrow.  The  second  toe  is  deformed  most 
often,  because  it  is  the  longest  and  because  it  suffers  most  from 
the  lateral  compression  as  well.  The  deformity  begins,  as  a  rule, 
in  early  childhood,  when,  the  growth  of  the  foot  being  rapid,  it 
is  more  likely  to  suffer  from  the  effects  of  outgrown  shoes,  and 
socks  as  well. 

Symptoms.  The  symptoms  are  practically  those  of  the  corns 
or  blisters  caused  by  the  pressure  of  the  shoe,  but  they  are  often 
sufficiently  troublesome  to  interfere  seriously  not  only  with  the 
comfort,  but  with  the  ability  of  the  patient. 

Treatment.  The  resistance  to  the  rectification  of  the  deformity 
is  caused  by  the  accommodative  changes  that  follow  habitual  mal- 
position. In  cases  of  long  standing  all  the  tissues  may  be  involved 
in  the  contraction,  of  which  the  most  resistant  are  the  shortened 
capsular  and  lateral  ligaments  of  the  first  interphalangeal  joint. 

The  congenital  hammer-toe  of  the  infant  may  be  treated  by 
manipulation.  When  the  resistance  is  overcome  the  toe  may  be 
held  in  proper  position  by  narrow  strips  of  adhesive  plaster 
passed  over  and  under  it  and  about  its  fellows.  In  older  children 
a  digitation  in  the  stocking  will  often  hold  the  toe  in  place  if  the 
deformity  is  slight  and  if  a  wide  shoe  is  worn.  In  adult  cases, 
in  addition  to  the  manipulation  and  shoe,  a  retention  apparatus, 
in  the  form  of  a  light  plantar  splint,  or  stiffened  inner  sole  to 
which  the  toe  can  be  attached,  should  be  worn.  If  the  deformity 
is  more  resistant  the  toe  may  be  straightened  by  force,  aided,  if 
necessary,  by  the  subcutaneous  division  of  the  contracted  ligaments ; 
but  in  advanced  cases  the  most  effective  treatment  is  resection 
of  the  joint.  Sufficient  bone  should  be  removed  to  permit  the  cor- 
rection of  the  deformity,  or,  in  case  of  its  recurrence,  to  prevent 
the  projection  of  the  joint  above  its  fellows.  A  splint  of  celluloid 
or  other  material  should  be  worn  for  a  time.  By  this  operation 
permanent  relief  may  be  assured,  and  it  is  to  be  preferred  to  the 
mutilation  of  amputation. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.     727 

Overlapping  Toes. 

Overlapping  toes  are  very  common  among  adults,  owing  to  the 
pressure  of  the  narrow  shoe ;  and  not  infrequently  such  deformity 
is  seen  in  infancy  and  is  apparently  congenital.  Deflected  or 
deformed  toes  may  be  treated  in  infancy  by  manipulation  and  by 
support  with  strips  of  adhesive  plaster  in  the  manner  described. 

In  childhood  exercise  and  proper  shoes  will  usually  correct 
acquired  deformity.  In  older  subjects  an  inner  sole  somewhat 
like  a  sandal,  to  which  the  toes  may  be  attached  by  bands  of 
tape,  may  be  employed  if  the  deformity  is  considered  by  the 
patient  of  sufficient  importance  to  demand  treatment. 

Exostoses  of  the  Foot. 

Simple  exostoses  of  the  foot,  as  distinct  from  those  that  are 
incidental  to  disease,  as,  for  example,  to  osteoarthritis,  are,  in 
most  instances,  induced  by  pressure  upon  a  projecting  bone 
of  a  somewhat  deformed  foot.  The  common  examples  are  the 
hypertrophy  of  the  navicular,  often  seen  in  flat-foot  of  young 
children,  the  projection  of  the  cuneiform  bones  on  the  dorsum  of 
the  hollow  or  contracted  foot,  the  enlargement  of  the  internal 
condyle  of  the  first  metatarsal  bone  complicating  hallux  valgus, 
and  the  exostoses  of  the  os  calcis  in  achillobursitis.  As  a  rule, 
the  treatment  of  the  deformity  of  the  foot  and  the  removal  of 
pressure  will  relieve  the  symptoms  without  other  treatment. 
Operative  removal  may  be  required  in  exceptional  cases. 

Fracture  of  Metatarsal  Bones. 

Fracture  of  a  metatarsal  bone,  most  often  the  second  or  the 
fifth,  may  occur  without  apparent  cause  other  than  walking. 
The  pain  and  the  subsequent  swelling  in  such  cases  may  be 
inexplicable  until  the  diagnosis  is  made  clear  by  an  X-ray  picture. 

Displacement  of  the  Peronei  Tendons. 

Permanent  displacement  of  these  tendons  forward  of  the  mal- 
leolus is  not  uncommon  as  a  result  of  paralytic  deformity,  par- 
ticularly talipes  calcaneus,  and  in  such  instances  it  gives  rise  to 
no  symptoms.  Displacement  of  one  or  both  of  the  tendons,  or 
rather  a  laxity  of  their  attachments  that  allows  an  occasional 
displacement  or  slipping  from  the  groove  behind  the  malleolus. 


728  OB THOPEDIG  S UB GEB  Y. 

may  result  in  serious  disability,  because  of  the  pain  that  follows 
the  displacement  and  because  of  the  weakness  and  insecurity  of 
which  the  patient  usually  complains. 

The  cause  of  the  laxity  of  the  tissues  that  allows  displacement 
in  feet  otherwise  normal  may  have  been  injury,  but  as  the  affec- 
tion is  often  bilateral,  the  predisposition  may  be  congenital. 

Treatment.  If  the  displacement  is  recent,  as  when  it  follows 
injury,  the  tendons  should  be  replaced,  and  the  foot  should  be 
fixed  in  a  plaster  bandage  until  repair  has  taken  place.  If,  as 
in  certain  instances,  dorsal  flexion  is  limited,  the  restriction 
should  be  overcome  before  the  bandage  is  applied.  If  the  dis- 
placement is  habitual,  a  brace  may  be  applied  to  restrain  those 
motions  at  the  ankle  that  induce  it.  In  the  chronic  cases  an 
operation  with  the  aim  of  fixing  the  tendons  by  deepening  the 
groove  in  the  malleolus,  or  by  suturing  the  displaced  sheath  in 
its  normal  position,  may  be  indicated.  If  on  examination  the 
cause  of  the  displacement  appears  to  be  a  shortening  of  the  tendon 
it  may  be  divided  and  lengthened  in  the  ordinary  manner. 

Shoes. 

The  shoe  as  a  factor  in  the  etiology  of  deformity  and  disability 
has  been  mentioned  several  times  in  the  preceding  pages,  but  it 
is  a  subject  of  such  importance  that  it  would  seem  to  call  for 
special  consideration. 

The  object  of  the  shoe  is  to  cover  and  protect  the  foot,  not  to 
deform  it  or  to  cause  discomfort ;  therefore,  the  one  should  corre- 
spond to  the  shape  of  the  other.  If  the  feet  are  placed  side  by 
side  the  outline  and  the  imprint  of  the  soles  will  correspond  to 
the  accompany iug  diagram  (Fig.  431).  The  outline  demonstrates 
the  actual  size  and  shape  of  the  apposed  feet,  emphasized  by 
enclosing  them  in  straight  lines.  Thus,  each  foot  appears  to  be 
somewhat  triangular,  being  broad  at  the  front  and  narrow  at  the 
heel.  The  imprint  shows  the  area  of  bearing  surface,  and  owing 
to  the  fact  that  but  a  small  portion  of  the  arched  part  of  the  foot 
rests  upon  the  ground  it  appears  to  be  markedly  twisted  inward. 
The  sole  of  the  shoe,  if  it  is  to  enclose  and  support  the  bearing 
surface,  must  also  appear  to  be  twisted  inward  in  an  exaggerated 
right  or  left  pattern.  It  will  be  straight  along  the  inner  border 
to  follow  the  normal  line  of  the  great  toe,  and  a  wide  outward 
sweep  will  be  necessary  in  order  to  include  the  outline  and  thus 
avoid  compression  of  the  outer  border  of  the  foot  (Fig.  432). 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      729 


This  demonstration  of  the  true  form  of  the  foot  is  almost  an 
indispensable  preliminary  to  an  intelligent  discussion  of  the  rela- 
tive merits  of  shoes,  and,  indeed,  it  is  somewhat  of  a  revelation  to 


Pig.  431. 


Fig.  432. 


Normal  feet. 


Proper  soles  for  normal  feet. 


those  who  have  thought  of  the  foot  only  as  it  has  been  subordinated 
to  the  arbitrary  and  conventional  standard  of  the  shoemaker.  The 
ideal,  or  shoemaker's  foot,  upon  which  lasts  are  fashioned,  is 
much  narrower  than  the  actual  foot ;  the  great  toe  is  not  a  power- 


FiG.  433. 


Fig.  434. 


Shoemaker's  feet. 


Shoemaker's  soles. 


ful  movable  member,  provided  with  active  muscles,  but  is  small 
and  turns  outward,  so  that  the  forefoot  is  somewhat  pyramidal  in 
form  and  turns  upward   as  if  to  avoid  contact  with  the  ground. 


730 


ORTHOPEDIC  SURGERY. 


This  imaginary  foot,  drawn  after  the  shape  of  the  ordinary  last, 
appears  in  the  diagrams  (Figs.  433  and  434).  Upon  it  the  sole 
of  the  shoe  has  been  indicated,  to  contrast  it  with  the  shape  of 
that  necessary  to  include  the  outline  of  the  normal  foot.  The 
actual  foot  is  thus  compressed  laterally  by  the   shoe  until  tlie 


Fig.  435. 


Skiagram  of  a  foot  modelled  to  fit  the  shoe,  illustrating  the  etiology  of  hallux  valgus. 


stretching  of  the  leather,  during  the  "  breaking-in "  process, 
allows  it  to  overhang  the  sole.  The  great  toe  is  forced  outward, 
and,  with  its  fellows,  is  compressed,  distorted,  and  lifted  off  the 
ground  by  the  rocker-shaped  sole  (Fig.  436).  Finally,  although 
in  the  foot  there  is  a  well-marked  metatarsal  arch  (convexity 
upward),  the  sole  is  almost  invariably  fashioned  with  a  convexity 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT.      731 

downward.  Thus  the  foot,  according  to  the  age  at  which  the 
reshaping  process  is  began  and  the  constancy  of  the  application, 
is  gradually  changed  in  shape  and  altered  in  function  (Fig.  435). 
This  remodelling,  however,  is  often  accompanied  by  such  dis- 
comfort that  the  individual  rebels  and  wears  a  shoe  with  a  square 
toe,  which,  from  the  conventional  standpoint,  is  supposed  to  show 
a  meritorious  effort  to  follow  nature.  But  the  demonstration  of 
the  actual  foot  makes  it  evident  that  it  is  a  properly  shaped  sole^ 
which  serves  as  a  support,  not  the  part  which  projects  beyond 
the  foot,  that  is  of  importance.  If  the  shoe  with  the  square  toe 
is  wider,  and  straighter  on  the  inner  side  than  another  with  a 
pointed  toe,  it  is  in  so  far  an  improvement.  But,  as  a  matter  of 
fact,  one  of  the  worst  types  of  shoe  provided  for  children,  in 
shape  very  like  the  old-fashioned  coffin-lid,  owes  its  popularity 
to  the  square  toe.  The  same  comment  may  be  made  on  the 
so-called  "  common-sense  "  shoe,  which  is  well  named,  since  it 
may  be  assumed  that  a  properly  shaped  shoe  is  an  evidence  of 
uncommon  sense. 

Fig.  436.  Fig.  437. 


The  rocker  sole.  The  flat  sole. 

The  object  of  the  heel  is  to  make  walking  easier  by  inclining 
the  body  somewhat  forward.  The  high,  narrow  heel  is  an 
insecure  support,  and  aids  deformity  by  throwing  more  strain 
upon  the  forefoot  and  pushing  it  forward  into  the  narrowest  part 
of  the  shoe.  The  heel  is,  of  course,  unnecessary  in  childhood, 
and  should  not  be  worn,  since  it  limits  the  necessity  for  and 
therefore  the  use  of  the  normal  range  of  motion  at  the  ankle- 
joint.  The  ordinary  shoe  by  restricting  the  functional  use  of 
the  foot,  favors  awkwardness  and  improper  attitudes.  It  com- 
presses the  toes,  and  is  directly  responsible  for  corns,  bunions, 
ingrown  toe-nails,  and  deformities,  and  indirectly  it  causes  or 
aggravates  nearly  every  weakness  to  which  the  foot  is  liable. 
This  assertion  does  not  need  support  of  argument,  since  in  some 
degree  it  has  been  proved  by  the  personal  experience  of  every 
shoe  wearer. 


732  OB THOPEDIC  S UB GEB  Y. 

The  shape  of  the  proper  shoe  corresponding  to  the  undistorted 
foot  has  already  been  demonstrated  (Fig,  432),  The  sole  should 
be  thick  enough  for  protection,  but  not  so  rigid  as  to  limit  normal 
motion ;  it  should  follow  the  imprint  of  the  foot,  projecting 
somewhat  beyond  the  outline  of  the  toes  ;  it  should  be  flat  from 
end  to  end  and  from  side  to  side  (Fig.  437),  and  the  upper  leather 
should  be  capacious.  In  other  words,  the  front  of  the  shoe 
should  be  designed  to  permit  and  to  encourage  normal  functional 
activity,  the  slight  adduction  of  the  great  toe,  and  the  alternate 
expansion  and  contraction  of  its  fellows,  as  may  be  observed  in 
the  barefoot  child.  The  heel  should  be  broad  and  low.  Most 
adult  feet  are  more  or  less  deformed,  and,  therefore,  better  suited 
by  an  improved  than  by  a  perfect  shoe.  Of  this  class,  what  is 
known  as  the  wide  Waukenphast  pattern  is  the  best.  In  select- 
ing the  better  from  the  worst  of  the  '*  ready-made "  shoes,  the 
breadth  of  sole,  the  angle  of  outward  deviation  of  the  soles  when 
the  two  are  placed  side  by  side,  and  the  capacity  of  the  upper 
leather  must  be  the  determining  points. 

The  most  effective  work  for  reform  can  be  accomplished  by 
providing  proper  shoes  for  children  and  thus  preventing  deformity. 
The  inspection  of  children's  feet  shows  that  atrophy  and  com- 
pression begin  at  a  very  early  age,  and  if  protection  could  be 
assured  during  the  period  of  rapid  growth,  serious  distortion 
might  be  prevented. 

Socks.  Although  of  far  less  importance  than  the  shoes,  the 
socks  worn  by  children  deserve  special  mention  as  a  factor  in 
deformity,  since  they  are  often  too  short  and  too  narrow  and  are 
made  of  unyielding  material,  so  that  the  proper  action  of  the  toes 
is  restrained.  Theoretically,  the  socks,  like  the  shoes,  should  be 
rights  and  lefts  ;  but  if  they  are  sufficiently  large  and  of  a  texture 
to  expand  readily  to  the  shape  of  the  foot,  but  little  trouble  need 
be  anticipated  on  this  score. 


CHAPTER   XXII. 

DEFORMITIES  OF  THE  FOOT. 

Talipes. 

In  the  preceding  chapters  the  disabilities  of  the  foot,  of  which 
the  symptoms  of  pain  and  discomfort  were  of  greater  importance 
than  actual  deformity,  have  been  described.  One  now  passes  to 
the  consideration  of  the  congenital  and  acquired  disabilities,  of 
which  deformity  is  the  most  noticeable  feature. 

Fig.  438. 


Paralytic  equinus.    liecovery  from  paralysis,  but  deformity  persists. 

Distortions  of  the  foot  are,  practically,  fixed  positions  in  normal 
attitudes  or  what  are  exaggerations  of  normal  attitudes  ;  in  other 
words,  the  ordinary  deformities  can  be  voluntarily  simulated,  and 
the  centres  of  motion,  at  which  the  foot  is  deformed,  are  the 
centres  of  normal   motion.      If  the  foot  has  been    fixed   in   the 


734  OR  THOPEDIC  S  UB GEB  Y. 

abnormal  attitude  during  the  period  of  formation  and  rapid 
growth,  or  if  it  has  been  used  for  any  length  of  time  in  the 
abnormal  position,  the  deformity  becomes  exaggerated  beyond 
the  possibility  of  imitation,  and  secondary  variations  in  its  shape, 
size,  and  nutrition  follow. 

The  deformities  of  the  foot  are  grouped  under  the  generic 
name  of  talipes,  derived  from  talus  (ankle)  and  pes  (foot),  signify- 
ing, therefore,  a  form  of  deformity  in  which  the  patient  walks 
upon  his  ankles.  Talipes  was  thus  originally  synonymous  with 
the  popular  term  club-foot,  but  at  the  present  time  it  is  used 
simply  as  a  prefix  to  the  descriptive  titles  of  the  different  distor- 
tions, while  club-foot  is  usually  applied  only  to  the  most  common 
of  the  congenital  deformities,  equinovarus,  in  which  the  distorted 
foot  is  club-like  in  form. 

Varieties.  There  are  four  simple  varieties  of  the  distorted  foot 
or  talipes  : 

1.  Talipes  equinus,  the  extended  or  plantar  flexed  foot.  In  well- 
marked  cases  the  patient  walks  upon  the  heads  of  the  metatarsal 
bones,  an  attitude  that  suggested  the  name  equinus  (horse-like). 

2.  Talipes  calcaneus,  the  dorsiflexed  foot,  in  which  the  heel  is 
prominent,  and  which  alone  bears  the  weight  in  walking;  hence, 
calcaneus  from  calcaneum,  the  heel  bone. 

In  these  forms  the  centre  of  motion  is  at  the  ankle-joint. 
Under  the  terms  equinus  and  calcaneus  are  included  not  only  the 
cases  of  marked  deformity,  but  also  those  in  which  the  range  of 
dorsal  or  plantar  flexion  is  sufficiently  limited  to  interfere  with 
function,  even  though  the  change  in  the  contour  of  the  foot  is 
slight. 

3.  Talipes  varus,  the  inverted  foot.  In  this  deformity  the  foot 
is  turned  in  or  adducted,  and  combined  with  the  inward  twist 
there  is  practically  always  a  certain  degree  of  supination  or 
inversion ;  that  is,  the  inner  border  of  the  sole  is  elevated  and 
the  outer  border  is  depressed,  so  that  the  weight  falls  to  the 
outer  side  of  the  centre  of  the  foot. 

4.  Talipes  valgus,  the  everted  foot.  This  deformity  is  the 
reverse  of  varus.  The  foot  is  abducted  and  the  sole  is  everted, 
so  that  in  use  the  weight  falls  on  the  inner  border. 

In  these  forms  of  lateral  deformity  the  centres  of  motion  are  at 
the  mediotarsal  and  subastragaloid  joints. 

These  simple  deformities,  in  which  the  foot  is  persistently 
extended  or  flexed,  or  twisted  in  or  out,  are  comparatively 
uncommon. 


DEFORMITIES  OF  THE  FOOT. 


735 


Compound  Deformities.  As  a  rule,  the  deformities  are  com- 
bined in  varying  degree ;  thus  the  overextended  or  the  overflexed 
foot  is  usually  twisted  inward  or  outward,  making  four  varieties 
of  compound  deformity  : 

1.  Talipes  equinovarus,  the  extended  and  inverted  foot. 

2.  Talipes  equinovalgus,  the  extended  and  everted  foot. 

3.  Talipes  calcaneovarus,  the  flexed  and  inverted  foot. 

4.  Talipes  calcaneovalgus,  the  flexed  and  everted  foot. 


Fig.  439. 


Congenital  calcaneus.    In  this  form  the  arch  is  obliterated  ;  iu  the  acquired  form 
it  is  increased. 

In  these  more  important  deformities  the  arch  of  the  foot  may 
be  increased  or  diminished  in  depth.  It  is,  for  example,  usually 
increased  in  calcaneus  and  equinus,  and  it  is  usually  diminished 
in  valgus;  but  this  secondary  or  subordinate  deformity  is  not 
recognized  in  the  ordinary  classification.  If  the  arch  of  the  foot 
is  simply  exaggerated,  tlie  condition  is  sometimes  called  pes 
cavus ;  if  it  is  lessened  or  lost,  it  is  called  pes  planus.  These 
slight  degrees  of  distortion,  in  which  the  functional  disability  is 
usually  more  important  than  th(!  (l(!formity,  arc  rarely  classed  as 


736 


ORTHOPEDIC  SURGERY. 


forms  of  talipes.  Simple  cavus,  the  hollow  or  contracted  foot, 
and  pes  planus,  one  of  the  forms  of  the  common  weak  or  flat-foot, 
have  been  described  elsewhere.     (Chapters  XX.  and  XXI.) 

Etiology.  From  the  remedial  standpoint,  the  cause  of  the 
deformity  is  of  far  greater  importance  than  its  form.  Thus,  one 
divides  the  distortions  of  the  foot  into  two  groups : 

1.  The  congenital  form,  in  which  the  foot,  in  process  of  forma- 
tion, has  slowly  grown  into  deformity  before  birth. 

2.  The  acctuired  form,  in  which  the  foot,  perfect  at  birth,  has  at 
a  later  time  become  distorted. 

The  congenital  club-foot  may  be  considered  simply  as  a  twisted 
foot,  of  which  the  component  parts,  although  distorted  to  a  greater 
or  less  degree,  are  capable  of  regaining  perfect  form  and  function. 


Congenital  valgus. 


This  is  practically  true  of  the  great  majority  of  cases,  although 
there  are  instances  in  which  congenital  deformity  is  complicated 
by  defective  formation  of  the  foot  or  leg,  or  in  which  the  defor- 
mity is  caused  or  at  least  accompanied  by  paralysis  ;  as,  for  example, 
in  certain  forms  of  spina  bifida  or  other  defect  or  disease  of  the 
nervous  apparatus. 

The  acquired  deformity  is  nearly  always  a  consequence  of 
paralysis  of  spinal  origin  (anterior  poliomyelitis).  Certain 
muscles  or  groups  of  muscles  being  paralyzed,  usually  in  early 
childhood,  the  muscular  force  of  the  foot  is  unbalanced,  and  it  is 
drawn  into  a  distorted  position  by  the  contraction  of  the  unop- 
posed muscles  and  by  the  influence  of  gravity.  This  distortion 
is  confirmed  and  increased  by  the  accommodative  changes  in  the 


DEFORMITIES  OF  THE  FOOT. 


737 


structure    that    accompany  functional    use   and    growth   in    the 
abnormal  attitude. 

Far  less  often  acquired  talipes  may  be  the  result  of  paralysis 
of  cerebral  origin,  of  other  forms  of  cord  disease,  and  of  local 
paralysis  following  neuritis  or  injury  to  a  nerve  trunk.  It  may 
be  caused  by  scar  contraction,  as  after  a  severe  burn,  or  by  direct 

Fig.  441. 


Congenital  club-hands  and  feet,  combined  with  anchylosis  of  nearly  all  the  joints/ 
(Compare  with  Fig.  442.) 


injury,  or  by  disease  that  may  interfere  with  subsequent  growth 
(Fig.  265).  Such  are,  however,  extremely  uncommon  causes. 
Thus  it  is  evident  that  whereas  congenital  talipes  is  a  simple 
distortion  capable  of  perfect  cure,  acquired  talipes  is  capable  only 
of  rectification  and  not  of  perfect  cure  unless  recovery  from  the 
original  disease,  of  which  it  is  a  result,  has  taken  place. 

47 


738 


OB  THOPEDIC  SUBGEB  Y. 


Etiology  of  Congenital  Talipes.  As  of  other  congenital  defor- 
mities, the  etiology  of  talipes  is  more  or  less  conjectural.  Occa- 
sionally the  influence  of  inheritance  is  apparent,  and,  again,  two 
or  more  children  with  club-foot  may  be  born  of  the  same  mother  ; 
but,  as  a  rule,  nothing  bearing  upon  the  deformity  appears  in 
the  family  or  personal  history.  The  most  reasonable  explanation 
as  applied  to  the  majority  of  cases  is  the  mechanical.  This  is, 
in  brief,  the  theory  that  the  foot  has  from  some  cause  remained 


Fig.  442. 


The  etiology  of  congenital  club-hands,  club-foot,  and  anchylosis  of  the  joints.    The  habitual 
attitude  at  birth.    Photograph  at  age  of  three  months.    (See  Fig.  441.) 

for  a  longer  or  shorter  time  in  a  constrained  or  fixed  position, 
and  has  thus  grown  into  deformity. 

It  has  been  claimed  by  Eschricht^  and  also  by  Berg^  that  about 
the  third  month  of  intra-uterine  life  the  thighs  of  the  embryo 
are  abducted,  flexed,  and  rotated  outward,  the  legs  are  crossed, 
and  the  feet  are  plantar  flexed  and  adducted,  so  that  the  inner 


1  Deutsche  klinik,  1851,  No.  44. 

2  Berg.    Archives  of  Medicine,  New  York,  December  1, 1882. 


DEFORMITIES  OF  THE  FOOT.  739 

surfaces  of  the  thighs,  the  tibial  borders  of  the  legs,  and  the 
plantar  surfaces  of  the  feet  are  held  in  close  apposition  to  the 
abdomen  and  to  the  pelvis  of  the  foetus.  Later  there  is  an  inward 
rotation  of  the  legs,  so  that  the  feet  are  turned  gradually  outward 
until  the  soles  are  brought  into  contact  with  the  uterine  wall,  the 
feet  then  being  in  the  attitude  of  abduction  and  dorsal  flexion. 
According  to  this  theory,  there  is  a  regular  succession  of  attitudes 
during  intra-uterine  life.  If  the  inward  rotation  of  the  lower 
extremity  is  prevented  or  if  it  is  incomplete,  the  foot,  remaining 
in  the  original  position,  becomes  deformed.  Thus  equiuovarus, 
being  the  normal  attitude  of  the  early  and  middle  period  of  intra- 
uterine life,  is  not  only  the  most  common,  but  it  is  the  most 
intractable  of  the  congenital  deformities.  But  if  the  constraint 
or  pressure  is  not  exerted  until  a  later  period,  after  rotation  has 
taken  place,  when  the  foot  has  attained  or  nearly  attained  its 
normal  size  and  shape,  it  will  then  induce  the  rarer  and  compara- 
tively slight  grades  of  deformity,  such  as  calcaneus  or  valgus. 

This  theory,  which  seems  interesting  and  reasonable,  appears 
to  rest  on  a  very  insecure  basis.  Bessel  Hagen^  states  that  in 
embryos  of  30  mm.  in  length  the  foot  is  in  extreme  plantar 
flexion  ;  in  those  of  90  to  100  mm.  the  foot  is  at  a  right  angle  to 
the  leg ;  and  from  this  size  to  that  at  full  term  the  foot  may  be 
found  in  any  position — abducted,  adducted,  or  dorsiflexed.  He 
states,  also,  that  supination  is  not  the  usual  attitude  at  an  early 
period,  but  is  more  common  near  the  termination  of  intra-uterine 
life,  and  when  it  is  present  it  is  more  often  combined  with  dorsi- 
flexion.  In  other  words,  there  is  no  time  when  the  foot  regularly 
and  normally  assumes  the  attitude  of  club-foot,  from  which  it  is 
changed  by  the  rotation  of  the  limbs.  Scudder,^  after  similar 
investigations,  arrived  at  practically  the  same  conclusions.  He 
states  that  there  is  no  necessary  relation  between  the  age,  the 
rotation  of  the  limbs,  and  the  position  of  the  feet. 

Although  the  rotation  theory  may  not  be  absolutely  accepted, 
still  it  would  appear  that  there  is,  during  the  process  of  develop- 
ment, a  more  or  less  regular  change  in  the  attitudes  of  the  limbs 
and  feet.  If  they  are  fixed  in  one  position  during  this  period  of 
rapid  growth,  distortion  must  follow  ;  if  the  constraint  is  slight, 
and  if  its  influence  is  exerted  at  a  late  period,  the  deformity  will 
be  slight ;  if  it  occurs  at  an  early  period,  the  deformity  will  be 
more  resistant. 

'  Die  Pathologie  und  Therapie  des  Klumpfusses  Heidelberg,  1899. 
2  Boston  Medical  and  Surgical  Journal,  October  27, 1887. 


740 


ORTHOPEDIC  SURGERY. 


One  of  the  causes  of  constraint,  and  thus  of  ultimate  deformity, 
appears  to  be  the  interlocking  of  the  feet.  Many  museum  speci- 
mens show  this,  and  in  some  of  the  cases  of  talipes  seen  during 
the  first  week  of  life  the  feet  may  be  replaced  in  the  attitude  in 
which  they  had  been  fixed  before  birth  (Fig.  281).  Intra-uterine 
pressure,  although  not  usually  the  direct  cause  of  club-foot, 
undoubtedly  has  an  influence  in  aggravating  the  deformity.  The 
effect  of  pressure  is  not  infrequently  shown  in  atrophic  areas  of 
skin,  and  bursse  even  are  sometimes  found  over  prominent  bones. 


Fig.  443. 


Intra-uterine  "  amputations."    The  patient  is  a  tailor. 


Entanglement  in  the  umbilical  cord,  the  direct  pressure  of  intra- 
uterine or  extra-uterine  tumors,  and  the  like  may  be  mentioned 
also  as  possible  causes. 

Evidence  of  restraint  and  of  abnormal  attitudes  of  the  limbs  is 
seen  not  infrequently  in  connection  with  club-foot ;  for  example, 
in  hyperextension  or  fixed  flexion  of  the  knees,  and  in  cases  of 
extreme  deformity,  the  foot  is  often  smaller  than  normal  and 
otherwise  asymmetrical.  The  distorted  foot  may  be  imperfect 
in  structure ;  toes  may  be  absent,  "  spontaneous  amputation " 
(Fig.  443),  or  constricting  bands  about  the  leg  or  foot  may  be 


DEFORMITIES  OF  THE  FOOT.  741 

present.  Such  abnormalities  are  usually  ascribed  to  amniotic 
adhesions.  Talipes  may  be  combined  with  evidences  of  impaired 
or  arrested  development ;  with  harelip,  extrophy  of  the  bladder, 
spina  bifida,  and  absence  of  patellae  ;  or  with  other  deformities, 
such  as  club-hand  and  wryneck,  fixed  flexion  at  the  knees,  and 
the  like ;  or  there  may  be  evidence  of  intra-uterine  disease,  as 
in  anchylosis  of  joints  (Fig.  441)  or  so-called  foetal  rickets. 
Finally,  deformities  of  the  foot  may  accompany  or  are  caused  by 
absence  of  bones,  as  of  those  of  the  foot ;  or  other  deformities 
and  malformations,  showing  evidently  an  abnormality  in  the 
original  make-up  of  the  germ.  This  latter  group,  which  includes 
the  complications  of  club-foot  and  imperfection  of  structure,  is 
comparatively  small,  and,  as  has  been  already  stated,  in  the 
great  majority  of  cases  congenital  club-foot  is  a  simple  deformity 
capable  of  perfect  cure. 

Statistics.  The  most  accurate  statistics  are  those  compiled 
from  the  records  of  the  Hospital  for  Ruptured  and  Crippled.^ 
In  the  combined  statistics  are  included  the  data  of  3453  indi- 
vidual cases  of  talipes.  Of  these  1650  were  congenital  and  1803 
were  acquired.  The  relative  frequency  of  the  congenital  and 
acquired  forms  of  talipes  has  given  rise  to  much  discussion  in 
the  past,  and  statistics  on  this  point  are  at  considerable  variance 
with  one  another.  This  may  be  explained  by  the  fact  that 
acquired  talipes  is,  as  a  rule,  a  preventable  deformity.  At  the 
present  time  the  extreme  degrees  of  acquired  talipes  are  compara- 
tively rare,  and  the  deformity  is  usually  of  a  much  slighter  grade 
than  the  corresponding  form  of  congenital  distortion. 

Males.  Females.          Total. 

Sex  of  congenital  talipes      ....    1065  585               1650 

Percentage 64.5  35.5 

Sex  of  acquired  talipes         ....      975  828                1803 

Percentage 54.1  45.8 

Congenital  talipes  is  much  more  common  among  males  than 
among  females.  All  statistics  are  in  accord  upon  this  point. 
Acquired  talipes  is  more  equally  divided  between  the  sexes. 

Right.  Left.  Both.  Total. 

Foot  affected  in  congenital  talipes  510  440  710  1660 

Percentage       .        .       .        .        30.7  26.5  42.7 

Unilateral  950  ^  57.2  per  cent.      Bilateral  710  =  42.7  per  cent. 

Right.  Left.  Both.  Total. 

Foot  affected  in  acquired  talipes    781  768  254  1803 

Percentage       .       .       .       .        43.3  42.6  14.1 

Unilateral  1519  =  85. 9  per  cent.       Bilateral  254  =  14, 1  per  cent. 


1  W.  R.  Townsend.    A  Statistical  Paper  on  Club-foot.    Transactions  of  the  Medical  Society 
of  the  State  of  New  York,  1890.    These  statistics  were  supplemented  for  me  by  Dr.  N.  B. 


Waller. 


742 


OB  THOPEDIC  S  UR  GEB  Y. 


In  congenital  talipes  the  deformity  is  nearly  as  often  of  both 
as  of  one  foot,  while  in  the  acquired  form  unilateral  deformity  is 
far  more  common.  In  each  variety  the  right  foot  appears  to  be 
more  often  affected  than  the  left. 

The  Eelative  Frequency  of  the  Different  Forms  of  Congenital 

Talipes. 

Cases.       Percentage. 

Equinovarus 1272                77.0 

Valgus 123                  7.4 

Varus 85                  5.1 

Calcaneovalgus 52                 3. 1 

Equinus 40                  2.4 

Calcaneus 28                  1.7 

Equinovalgus 28                  1.7 

Calcaneovarus 7 

Cavus 6 

Valgccavus 1 

Equinocavus       .                1 

Diflferent  deformity  in  each  foot 18 

Total 1660 

Relative  Frequency  of  the  Different  Forms  of  Acquired  Talipes 
Together  with  the  Etiology. 


Spinal. 

Cerebral. 

Other 
forms  of 

Trau- 

Total. 

Anterior 

polio- 
myelitis. 

Per  ct. 

Hemi- 

Para- 

paralysis. 

matic. 

plegia. 

plegia. 

575 

Equinovarus 

479 

28 

35 

4 

29 

32.5 

Equinus . 

321 

66 

46 

3 

26 

462 

26.1 

Calcaneus 

219 

3 

1 

0 

1 

224 

12.6 

Valgus    . 

134 

4 

7 

1 

27 

173 

9.7 

Equinovalgus 

114 

0 

5 

0 

3 

122 

6.9 

Calcaneovalgus 

76 

0 

0 

0 

2 

78 

4.4 

Varus     . 

41 

2 

1 

0 

5 

49 

2.7 

Calcaneocavus 

12 

0 

0 

0 

0 

12 

Equinocavus 

22 

0 

0 

0 

2 

24 

L3 

Calcaneovarus 

11 

0 

0 

0 

0 

11 

Cavus     . 

35 

1 

0 

0 

0 

36 

2.0 

Varocavus     . 

1 

1 

0 

0 

0 

2 

1465 

105 

95 

8 

95 

1768 

Deformity  diflferent  on  each  side 

50 

Anterior  poliomyelitis 1465  =  82.8  per  cent. 

Cerebral 200  =  11.3 

Traumatic 95  =    5.3       " 


Comparative  Frequency  of  the  Different  Forms  of  Talipes, 
Congenital  and  Acquired. 

Congenital.  Acquired. 

Equinovarus 77. 0  per  cent.  32. 5  per  cent. 

Valgus 7. 4        "  9. 7        ■ 

Varus 5.1        "  2.7 

Calcaneovalgus 3. 1        "  4.4 

Equinus 2. 4        "  26.1 

Calcaneus 1. 7       "  12.6 

It  will  be  noted  that  in  three-fourths  of  the  congenital  cases 
the   deformity  is  equinovarus,  and  that  equinus  and   calcaneus, 


DEFORMITIES  OF  THE  FOOT.  743 

rare  as  congenital  deformities,  comprise  38  per  cent,  of  the 
acquired  forms. 

Occasionally  the  deformity  is  different  in  each  foot,  far  more 
often  in  the  acquired  than  in  the  congenital  form  (50  of  the 
former,  or  19  per  cent.,  of  the  254  acquired  bilateral  deformities 
as  compared  with  18,  or  less  than  3  per  cent.,  of  the  bilateral  con- 
genital). In  7  of  the  18  congenital  cases  the  deformity  was 
equinovarus  on  one  side,  calcaneus  on  the  other;  in  3,  equino- 
varus  and  calcaneovalgus,  and  in  3,  simple  varus  and  valgus. 
'The  50  cases  of  acquired  talipes  represented  every  combination 
!of  deformity. 

In  31,  or  4  per  cent.,  of  the  735  cases  of  congenital  talipes 
tabulated  by  Waller  the  distortion  was  combined  with  other  con- 
genital defects  or  deformities,  viz.,  in  12  cases  with  double  club- 
hands; in  6  cases  with  defective  development  of  the  hands, 
webbed  fingers,  and  the  like ;  in  7  cases  with  spina  bifida ;  in  3 
cases  with  absence  of  one  or  more  bones  of  the  leg ;  in  1  case 
with  torticollis ;  in  1  case  with  harelip ;  in  1  case  with  disloca- 
tion of  the  knee  and  anchylosis  of  an  elbow ;  in  2  cases  with 
general  rigidity  and  deformity  of  the  joints. 

The  Anatomy  of  Congenital  Club-foot.  Talipes  Equinovarus. 
Congenital  talipes  is,  in  the  great  majority  of  cases,  the  form  in 
which  the  foot  is  twisted  inward  and  downward,  so  that  in 
extreme  cases  it  resembles  the  club -like  extremity  that  has  re- 
ceived the  popular  name  of  club-foot.  The  ordinary  congenital 
club-foot,  in  early  infancy,  is  simply  a  foot  held  in  an  exagger- 
ated attitude  of  plantar  flexion,  adduction,  and  supination.  The 
dorsum  of  the  foot  looks  forward  and  slightly  outward  and 
upward,  the  plantar  surface  is  abnormally  concave,  and  looks 
backward,  inward,  and  downward.  The  foot  often  seems  some- 
what smaller  than  normal,  and  the  heel  appears  to  be  ill-formed. 
Upon  the  outer  dorsal  surface  the  body  of  the  displaced  astragalus 
projects ;  the  external  malleolus  is  prominent,  while  the  internal 
malleolus  lies  deep  beneath  the  redundant  tissues  of  the  internal 
aspect  of  the  foot. 

In  many  instances  the  turning  inward  of  the  foot  is  so  extreme 
that  it  conceals  the  equinus  element  of  the  deformity  (Fig.  444). 
Thus  equinovarus  is  often  classified  as  varus,  especially  by  Eng- 
lish authors. 

The  internal  structure  of  the  foot  is  rearranged  to  correspond 
to  the  external  contour ;  thus  the  relation  of  the  bones  to  one 
another,  and  even  the  shape  of  the  individual  bones,  are  more  or 


744 


ORTHOPEDIC  SURGERY. 


less  altered  as  the  deformity  is  more  or  less  o£  an  exaggeration  of 
the  attitudes  that  the  normal  foot  is  capable  of  assuming.     These 


'^ 


Typical  congenital  equinovarus  (club-foot). 


Fig.  445. 


The  deformities  of  the  astragalus  in  club-foot.  A,  astragalus  of  a  normal  infant ;  1,  from 
above ;  2,  from  within ;  3,  from  without.  B,  the  astragalus  in  club-foot  in  the  same  posi- 
tions.   (Adams.) 

changes  are  most  marked  in  the  astragalus  and  os  calcis.  The 
astragalus  is  thicker  at  its  external  than  at  its  internal  border, 
or   somewhat  wedge-shaped  from  without  inward;  it  is  plantar 


DEFORMITIES  OF  THE  FOOT.  745 

flexed,  so  that  a  large  part  of  its  body  protrudes  from  between  the 
malleoli.  Its  neck  is  often  somewhat  longer  than  normal,  and 
it  is,  as  a  rule,  depressed  and  deflected  inward  (Fig.  445,  B). 
The  OS  calcis  is  also  in  an  attitude  of  plantar  flexion  ;  the  internal 
tuberosity  is  drawn  upward  to  the  vicinity  of  the  internal  malleo- 
lus, its  anterior  extremity  looks  downward  and  inward,  and  it  is 
often  bent  inward,  corresponding  to  the  deformity  of  the  neck  of 
the  astragalus.  Its  external  surface  looks  downward  and  for- 
ward, and  it  lies  directly  beneath  the  astragalus  instead  of  to  its 
outer  side,  as  in  the  normal  relation. 

The  navicular  is  drawn  inward  and  upward,  and  articulates 
with  the  inner  part  of  the  deflected  head  of  the  astragalus ;  it 
lies  in  close  proximity  to  and  is  often  in  contact  with  the  internal 
malleolus ;  the  cuboid  is  displaced  upward  and  inward,  and  lies 
to  the  inner  side  of  the  anterior  extremity  of  the  os  calcis.  The 
remaining  bones  are  changed  in  position,  but  not  materially  in 
shape.  In  many  instances  the  tibia  is  rotated  inward  upon  the 
femur,  and  this  inward  rotation  of  the  leg  may  persist  after  the 
deformity  of  the  foot  has  been  corrected.  Less  often  the  tibia  is 
slightly  twisted  inward  on  its  long  axis.  In  other  cases  there  is 
often  a  moderate  degree  of  knock-knee  and  laxity  of  the  liga- 
ments at  the  knee.  As  a  rule,  however,  these  are  secondary  or 
compensatory  effects  of  club-foot  that  do  not  appear  until  the 
child  begins  to  walk. 

The  ligaments  are  altered  to  correspond  to  the  changed  rela- 
tions of  the  bones.  Those  on  the  short  side  are  more  or  less 
resistant,  according  to  the  duration  of  the  deformity.  The 
muscles  are  normal  as  to  their  structure  and  their  origin  and 
insertion,  but  the  direction  of  the  tendons  as  they  pass  across  the 
foot  is  altered  somewhat.  Those  attached  to  the  inverted  side, 
the  extensor  and  adductor  group,  are  shortened  and  are  relatively 
stronger  than  those  on  the  outer  side,  which  are  lengthened  and 
atrophied  from  disuse. 

To  sum  up :  all  the  component  parts  of  the  foot  participate  in 
the  deformity.  The  most  noticeable  changes  in  the  bones  are  in 
their  position  and  relation  to  one  another,  but  the  astragalus,  os 
calcis,  and  navicular  bones  are  usually  distinctly  abnormal  in 
contour. 

The  most  resistant  structures  in  the  deformed  foot  are  the 
plantar  fascia  and  the  ligaments  that  bind  the  scaphoid,  the  os 
calcis,  and  the  internal  malleolus  to  one  another.  The  muscles 
that  are  most  active  in  retaining  and  increasing  the  deformity  are 


746 


ORTHOPEDIC  SURGERY. 


the  tibialis  anticus,  the  tibialis  posticus,  and  the  combined  gas- 
trocnemius and  soleus. 

The  changes  that  have  been  outlined,  which  are  comparatively- 
slight  and  which  may  be  easily  rectified  soon  after  birth,  become 
more  marked  as  the  part  develops ;  and  when  the  child  begins 
to  walk  the  weight  of  the  body,  combined  with  growth  and  func- 
tional use  in  the  abnormal  position,  increases  and  fixes  the 
deformity. 

In  the  adolescent  or  adult  type  of  club-foot  that  has  never 
been  treated  the  deformity  is  so  extreme  that  the  patient  actually 

appears  to  walk  on  the  out- 


FiG.  446. 


side  of  his  ankles,  as  the  term 
talipes  implies.  The  feet 
turn  directly  inward,  or  even 
inward,  upward,  and  back- 
ward, and  the  peculiar  walk, 
by  which  interference  of  in- 
verted feet  is  avoided,  has 
given  another  name  (reel 
foot)  to  the  deformity. 

In  such  cases  knock-knee 
is  usually  well  marked. 
This,  although  it  may  be 
present  at  birth,  is,  as  has 
been  stated,  usually  a  second- 
ary distortion  caused  in  great 
part  by  the  accommodation 
to  the  deformity ;  that  is,  by 
the  diminution  of  the  base 
of  support  and  by  the  inter- 
ference of  the  feet  (Fig.  449.) 

The  legs  are  shrunken 
from  disuse.  Over  the  outer 
border  of  the  foot,  in  the 
neighborhood    of    the    cal- 

Talipes  equinovarus  in  adolescence,  apparently  i     'i  +•      1    j-" 

of  the  acquired  form,  showing  the  displacement  of  CaneOCUDOlCl  artlCUlatlOU, 

the  astragalus  and  its  relation  to  the  scaphoid,  also  +]-iprp    ja    q    larP^e    CalluS  with 
the  atrophy  and  distortion  of  the  bones  of  the  leg.  '  _      ° 

an  underlying  bursa.  The 
foot  itself  is  atrophied  and  is  much  smaller  than  the  normal.  The 
changes  in  the  bones  are  much  more  marked  ;  only  a  small  part 
of  the  articulating  surface  of  the  astragalus  lies  between  the 
malleoli,  and  this  posterior  extremity  is  flattened  out  to  the  shape 


DEFORMITIES  OF  THE  FOOT. 


747 


of  a  wedge.  There  is  consequently  backward  displacement  of  the 
leg  bones,  which  is  most  apparent  in  the  position  of  the  external 
malleolus.  In  fact,  the  changes  in  the  foot  may  be  so  great  as 
to  make  the  component  parts  almost  unrecognizable  (Figs.  444, 
445,  and  446).  All  the  bones  of  the  foot  are  more  or  less 
atrophied,  and  the  normal  area  of  cartilage  has,  to  a  great  extent, 
disappeared  from  the  articular  surfaces  of  the  disused  joints. 


Pig.  447. 


Fig.  448. 


Talipes  equinovarus. 
The  tendons  on  the  front  of  the  foot.  Showing  the  tendons  in  the  sole  of  the  foot  and 

the  extreme  displacement  of  the  os  ealcis. 


In  this  advanced  stage  the  normal  functional  activity  of  the 
foot  has  disappeared.  It  is  practically  a  simple  rigid  support, 
to  which  the  patient  has  been  so  long  accustomed  that  he  may 
walk  with  comparative  case  and  with  no  discomfort  other  than 
that  caused  by  the  corns  and  bunions  at  the  pressure  points.  In 
these  extreme  cases,  cure  in  the  sense  of  perfect  functional 
recovery    is,    of  course,    out  of  the  question  ;  but   relief   of  the 


748  ORTHOPEDIC  SURGERY. 

deformity — that  is,  replacement  of  the  foot  in  the  axis  of  the  leg, 
at  a  right  angle  to  it  and  in  the  plantigrade  attitude — is  nearly 
always  possible. 

Symptoms,  The  symptoms  of  congenital  club-foot  have  been, 
to  all  intents,  included  in  the  description  of  the  deformity.  The 
functional  disability  is,  of  course,  considerable,  although  some 
patients  are  surprisingly  active  and  are  able  to  walk  long  dis- 
tances. As  the  discomfort  from  club-foot  is  due  almost  entirely 
to  the  corns  or  inflamed  bursee  over  the  bony  prominences,  its 
degree  depends,  of  course,  upon  the  use  to  which  the  foot  is  sub- 
jected. 

Treatment.  In  considering  the  treatment  of  congenital  club- 
foot it  is  customary  to  divide  it  into  several  classes  corresponding 
to  the  degree  of  resistant  deformity. 

The  first  class  would  include  the  very  slight  or  non-resistant 
cases  in  which  the  deformity  may  be  almost  entirely  corrected  by 
slight  manual  force. 

The  second  class  comprises  those  cases  in  which  a  certain 
amount  of  varus  and  well-marked  equinus  remain,  which  it  is 
impossible  to  overcome  by  manipulation. 

The  first  and  second  classes  include  the  forms  of  infantile 
club-foot. 

The  third  class  comprises  the  cases  of  more  extreme  deformity 
and  those  in  which  the  resistance  to  the  correction  is  great,  as  in 
many  of  the  cases  in  early  childhood  or  those  of  later  years  that 
have  been  inefficiently  treated. 

A  fourth  class  would  include  the  untreated  cases  in  the  adoles- 
cent or  adult. 

Congenital  club-foot  (talipes  equinovarus)  treated  at  the 
proper  time — that  is  to  say,  in  early  infancy  and  in  a  proper 
manner — in  a  great  majority  of  cases  may  be  perfectly  cured  both 
as  to  form  and  function. 

The  club-foot  in  childhood,  in  which  treatment  has  been  de- 
layed or  in  which  it  has  been  ineffective,  may  be  practically 
cured  as  to  form  and  function,  but  a  certain  amount  of  atrophy 
of  the  foot  and  leg  persists  as  a  consequence  of  the  disuse  of  the 
distorted  part. 

Club-foot  in  the  adult  may  be  made  straight,  but  perfect  func- 
tional cure  is,  of  course,  impossible. 

Although  congenital  club-foot  is  an  eminently  curable  defor- 
mity, yet  perfect  and  permanent  cure  requires  minute  attention 
to  details  during  the  active  stage  of  treatment,  supplemented  by 


DEFORMITIES  OF  THE  FOOT.  749 

long-continued  and  careful  supervision  after  the  cure  is  supposed 
to  be  complete.  No  other  deformity  presents  such  a  record  of 
failures  and  incomplete  cures,  of  relapses  after  apparent  cure,  of 
tedious  and  ineffective  treatment  by  braces,  and  of  unnecessary 
and  mutilating  operations.  Some  of  the  failures  may  be  explained 
by  the  neglect  of  the  parents  or  by  want  of  opportunity.  A  few 
are  due  to  the  unusual  obstacles  in  the  deformity  itself,  but  by 
far  the  greater  number  must  be  accounted  for  by  failure  of  the 
physician  to  apj)rehend  the  true  nature  of  the  deformity  or  by 
his  inexperience  in  the  practical  details  of  treatment. 

Principles  of  Treatment  of  Infantile  Club-foot,  The  infantile 
club-foot  is,  as  has  been  stated,  simply  a  twisted  foot.  It  is  true 
that  there  are  slight  changes  in  the  bones ;  but  the  bones  of  an 
infant's  foot  are  represented  by  yielding  cartilage,  which  will 
rapidly  reform  under  changed  conditions.  The  ligaments,  which 
are  accommodated  to  the  deformity,  may  be  easily  stretched, 
together  with  the  more  resistant  muscles  and  their  tendinous 
insertions,  and  when  the  proper  relation  of  the  bones  to  one 
another  has  been  restored  the  joints  will  undergo  an  accommoda- 
tive transformation. 

The  treatment  of  club-foot  may  be  divided  into  three  stages : 

1.  The  rectification  of  the  external  deformity. 

2.  The  support  of  the  foot  in  proper  position  during  the 
process  of  transformation  of  its  internal  structure  and  until  the 
normal  muscular  power,  unbalanced  by  the  deformity,  has  been 
regained. 

3.  The  period  of  supervision.  This  would  include  the  treat- 
ment of  possible  complicating  deformities  at  the  knee,  the  laxity 
of  ligaments  and  the  like,  as  well  as  the  oversight  of  the  func- 
tional use  of  the  foot  and  the  limb  during  the  early  years  of  life. 

On  examining  the  infantile  club-foot  one  will  notice  the  same 
muscular  activity  that  characterizes  the  normal  foot.  The  normal 
infant  moves  the  foot  in  various  directions,  in  a  more  or  less 
regular  alternation  of  postures,  but  the  motion  of  the  club-foot  is 
in  one  direction  only,  that  toward  which  the  foot  is  turned.  The 
muscles  on  the  back  and  inner  side  of  the  leg,  which  are  alone 
active,  become  relatively  irritable  and  hypertrophied  as  compared 
with  those  on  the  front  and  outer  side  that  are  disused.  Thus 
muscular  activity  of  the  deformed  foot  is  in  reality  harmful, 
because  it  increases  deformity  and  still  further  disturbs  the  mus- 
cular balance.  For  this  reason  the  temporary  restraint  of  motion, 
necessary  during  the  rectification  of  the  deformity,  may  be  con- 


750  ORTHOPEDIC  SUBOEBY. 

sidered  rather  of  advantage  than  otherwise.  When  movement 
is  again  allowed  and  encouraged  it  must  be  in  the  directions 
opposed  to  the  attitudes  of  deformity,  with  the  aim  of  so  strength- 
ening the  weakened  group  of  muscles  at  the  expense  of  the 
stronger  that  the  balance  of  muscular  power  may  be  re-established. 

The  First  Stage  of  Treatment.  Rectification  of  Deformity.  It 
should  be  stated  at  once  that  "  rectification  of  deformity "  does 
not  mean  apparent  symmetry,  a  misapprehension  to  which  the 
majority  of  failures  in  treatment  may  be  ascribed.  It  means  that 
when  deformity  is  really  rectified  all  contracted  and  resistant 
parts  must  have  been  so  elongated  that  every  passive  motion  and 
attitude  possible  for  the  normal  foot  is  equally  possible  and  as 
easily  attained  in  that  which  was  deformed.  This  is  functional 
rectification  as  contrasted  with  the  simple  straightening  of  external 
deformity. 

The  most  important  part  of  the  club-foot  deformity  is  varus. 
The  foot  that  is  rolled  over  and  twisted  inward  to  the  attitude 
of  extreme  adduction  (Fig.  444)  must  be  untwisted  and  forced 
into  an  attitude  of  extreme  abduction  or  valgus,  the  so-called 
overcorrection  (Fig.  440).  Until  this  is  accomplished  no  atten- 
tion whatever  need  be  paid  to  the  residual  equinus.  There  are 
two  reasons  for  dividing  the  procedure  into  two  parts :  First,  that 
the  attention  of  the  surgeon  may  be  concentrated  on  one  and  the 
most  important  part  of  the  deformity ;  second,  because  by  this 
preliminary  untwisting  the  os  calcis  is  brought  into  the  upright 
position,  into  its  proper  relation  to  the  astragalus,  to  the  bones 
of  the  leg,  and  to  the  tendo  Achillis,  so  that  the  true  degree  of 
equinus  may  be  appreciated. 

Preliminary.  Manipulation.  As  a  rule,  the  second  or  third  week 
of  life  is  as  early  as  mechanical  treatment  can  be  undertaken. 
Until  then  preliminary  manipulation  by  the  nurse,  more  particu- 
larly manual  straightening  of  the  deformity  by  gently  drawing  the 
foot  toward  abduction  and  retaining  it  in  the  improved  position 
for  a  few  minutes,  as  often  as  is  possible,  may  be  of  service  in 
overcoming  its  resistance.  As  a  treatment  by  itself,  however, 
simple  manual  correction  is  tedious  and  ineffective,  although 
partial  cures  have  been  attained  by  perseverance  in  this  means 
alone. 

Mechanical  Treatment.  This  is  the  treatment  of  choice  and 
routine  for  infantile  club-foot,  and  two  methods  may  be  described : 

1.  By  the  plaster  bandage. 

2.  By  some  form  of  simple  splint. 


DEFORMITIES  OF  THE  FOOT. 


751 


The  principle  of  the  two  is  essentially  the  same.  The  foot  is 
drawn  toward  an  improved  position  and  retained  there  by  the 
plaster  bandage,  or  it  may  be  fixed  to  some  form  of  metal  splint 
or  brace  whose  shape  is  gradually  changed  from  week  to  week, 
as  the  resistance  lessens. 

Gradual  Rectification  of  Deformity  by  Means  of  the  Plaster 
Bandage.  In  this  treatment  care  should  be  taken  to  avoid  undue 
pressure,  irritation  of  the  skin,  or  insecurity  of  the  bandage. 
One  should  place  shreds  of  cotton  between  the  toes ;  and  the 
outer  aspect  of  the  ankle,  where  the  skin  is  thrown  into  folds 


Neglected  club-loot,  showing  the  secondary  knock-knee. 

when  the  foot  is  straightened,  should  be  smeared  with  vaseline. 
A  narrow  strip  of  adhesive  plaster,  long  enough  to  reach 
from  the  knee  to  a  point  an  inch  or  more  below  the  heel,  is 
applied  to  the  outer  side  of  the  leg.  A  thin  layer  of  cotton  is 
wound  about  the  leg,  just  below  the  knee,  in  order  to  protect  tiie 
skin  from  the  hard  margin  of  the  plaster  bandage,  and  a  similar 
strij)  is  carried  about  the  toes.  The  foot  is  then  drawn  gently 
toward  the  abducted  position  as  far  as  may  be  without  causing 
discomfort.  Wliilo  it  is  held  m  this  attitude  a  narrow  bandage, 
preferably  flannel  or  cotton  flannel,  is  smoothly  applied  to  the  leg 


752  ORTHOPEDIC  SUBOEBY. 

and  foot,  the  band  of  adhesive  plaster  being  drawn  out  between  the 
folds  about  the  ankle.  A  very  light  plaster  bandage  is  then  applied 
from  the  upper  part  of  the  leg  to  the  extremities  of  the  toes,  and 
into  this  bandage  the  projecting  strip  of  adhesive  plaster  is 
incorporated,  so  that  no  displacement  of  the  dressing  is  possible. 
The  turns  of  both  the  plaster  and  the  flannel  bandage  should  be 
made  from  within,  downward  and  outward,  so  that  the  tension  aids 
in  retaining  the  foot.  When  the  plaster  bandage,  which  during  the 
hardening  process  has  been  constantly  rubbed  and  manipulated  so 
that  it  may  fit  the  part  perfectly,  and  which  need  not  be  thicker 
than  blotting  paper,  has  become  firm,  a  long  stocking  is  drawn 
over  it  and  is  attached  to  the  body  clothing.  At  the  end  of  a 
week  the  bandage  is  removed.  The  leg  and  foot  are  gently  bathed 
with  alcohol,  thoroughly  dried,  powdered,  and  protected  as  before, 
and  the  bandage  is  again  applied.  At  this  second  dressing  the 
irritable  adductiug  muscles,  after  the  interval  of  complete  rest, 
will  be  much  less  active  and  the  contracted  tissues  will  be  less 
resistant,  so  that  the  foot  may  be  easily  turned  somewhat  out- 
ward or  beyond  the  line  of  the  leg. 

After  four  or  five  applications  of  the  bandage,  at  weekly  inter- 
vals, the  foot,  in  ordinary  cases,  can  be  held  without  resistance 
in  the  attitude  of  extreme  equinovalgus.  The  sole,  which  at 
first  looked  backward,  inward,  and  upward,  will  be  turned  in  the 
opposite  direction,  forward,  outward,  and  downward,  and  the 
inner  border  of  the  foot,  which  was  concave,  is  now  convex 
(Fig.  440).  When  the  varus  has  thus  been  overcorrected,  treat- 
ment is  directed  to  the  secondary  equinus.  At  this  stage  it  is 
well  to  cover  the  bottom  of  the  foot  with  a  foot  plate  of  thin 
wood  (splint  wood  or  cigar-box  cover)  to  give  the  plaster  bandage 
more  solidity,  and  in  order  that  its  pressure  may  aid  in  flattening 
the  rounded  sole.  At  first  one  carries  the  foot  upward  (toward 
dorsal  flexion),  while  it  is  still  retained  in  the  abducted  position, 
but  when  the  right-angled  attitude  has  been  attained  it  is  brought 
nearer  to  the  axis  of  the  leg.  The  everted  position,  or  the 
attitude  opposed  to  varus,  is  retained,  however,  until  correction 
is  completed.  In  correcting  the  equinus  a  certain  amount  of 
force  is  required,  sufficient  to  cause  some  discomfort  during  the 
application  of  the  plaster,  but  not  sufficient  to  occasion  suffering 
afterward.  The  force  is  applied  by  means  of  the  sole  plate  to 
the  entire  foot,  so  that  the  posterior  extremity  of  the  os  calcis 
may  be  drawn  downward  by  actual  lengthening  of  the  tendo 
Achillis,  and  not,  as  is  often  the  case,  by  an  overcorrection  of  the 


DEFORMITIES  OF  THE  FOOT. 


753 


forefoot,  while  the  heel  remains  in  its  original  position  of  plantar 
flexion.  By  the  proper  application  of  force  the  equinus  is  gradu- 
ally overcome  ;  the  sharp  indentation  or  fold  at  the  insertion  of 
the  tendo  Achillis  is  lessened,  and  the  heel  becomes  more 
prominent. 

The  reduction  of  the  equinus  may  be  somewhat  more  difficult 
than  that  of  the  varus,  but  it  should  be  entirely  corrected  in 
three  or  four  months  from  the  time  of  beginning  the  treatment. 
As  has  been  stated,  correction  of  the  deformity  implies  overcor- 


The  first  application  of  the  plaster  bandage,  showing  the  improved  position. 
(Compare  with  Fig.  444.) 


rection  (Fig.  439) ;  and  it  is  well,  when  this  has  been  attained, 
to  hold  the  foot  for  several  weeks,  by  means  of  the  plaster 
bandage,  in  an  attitude  of  extreme  pronation  and  dorsal  flexion 
(calcaneovalgus)  in  order  to  impress,  as  it  were,  the  new  position 
upon  its  structure.  This  concludes  the  first  stage  of  the  treat- 
ment, the  simple  rectification  of  deformity. 

Correction  by  the  ])laster  bandage  has  the  great  advantage 
of  placing  the  treatment  entirely  under  the  control  of  the  sur- 
geon.    When  properly  applied,  the  support  fits  perfectly,  it  is 

48 


754  ORTHOPEDIC  SUBGEBY. 

light  and  clean,  and  it  holds  the  foot  in  the  desired  attitude  with- 
out undue  pressure. 

The  disadvantages  of  the  treatment  are  due  almost  entirely  to 
its  improper  application.  For  instance,  the  bandage  may  be  too 
heavy,  or  the  padding  may  be  so  thick  that  it  does  not  retain  its 
position.  Excoriations  are  usually  due  to  carelessness  in  the 
application  of  the  bandage,  or  because  it  is  not  removed  in 
proper  season.  The  fear  of  compression,  of  atrophy  of  muscles, 
of  stunting  the  growth  of  the  limb  is  groundless.  At  the  end  of 
the  plaster-of-Paris  treatment,  the  corrected  foot  is,  as  a  rule, 
larger  than  one  that  has  remained  untreated.  The  stunted  foot 
is  the  result  of  non-treatment,  or  of  ineffective  treatment  by 
braces  or  otherwise ;  not  of  the  enforced  rest  necessitated  by  the 
proper  reduction  of  deformity. 

The  Eectification  of  Deformity  by  Splints  and  Braces.  Of 
mechanical  supports  there  are  many  varieties.  Complicated 
appliances  should  be  avoided  because  they  are  unnecessary  and 
because  they  serve  to  distract  attention  from  the  prime  object  of 
treatment,  the  rapid  and  systematic  correction  of  deformity.  Of 
the  simpler  braces  that  used  by  Judson  is  one  of  the  best  and 
will  serve  as  a  type  to  illustrate  this  form  of  treatment.  The 
method  of  application  may  be  described  in  Judson' s  own  words: 
"  The  apparatus  which  I  have  conveniently  used  to  effect  this 
reduction  before  the  child  learns  to  stand  is  a  simple  retentive 
brace  which  acts  as  a  lever,  making  pressure  on  the  outer  side 
of  the  foot  and  ankle  at  A,  in  Figs.  451  to  454,  inclusive,  and 
counter-pressure  at  two  points,  one  on  the  inner  side  of  the  leg 
at  B,  and  the  other  at  the  inner  border  of  the  foot  at  C  It  is 
advisable  to  keep  in  mind  that  this  simple  instrument  is  a  lever, 
because  if  we  know  that  we  are  using  a  lever  with  its  three  well- 
defined  points  of  pressure  we  can  make  the  apparatus  more 
efficient  than  if  we  view  it,  in  a  more  general  way,  as  an  apparatus 
for  giving  a  better  shape  to  the  foot. 

"  1  use  a  little  brace  made  of  sheet  brass,  doing  the  work  with 
a  few  simple  tools.  An  advantage  of  doing  the  work  one's  self 
is  that  there  is  no  room  for  doubt  as  to  where  the  blame  lies  if 
the  apparatus  does  not  work  well.  Two  curved  disks,  B  and  C, 
Figs.  453  and  454,  are  riveted  to  a  shank,  D,  and  thus  is  formed 
that  part  of  the  brace  which  applies  the  two  points  of  counter- 
pressure  ;  while,  on  the  other  hand,  the  point  of  pressure  is 
brought  into  action  by  a  third  disk  or  shield.  A,  which  is  drawn 
tightly  against  the  outer  side  of  the  foot  and  ankle,  and  held  in 


DEFORMITIES  OF  THE  FOOT. 


755 


place  by  a  strip  of  adhesive  plaster,  E,  which  includes  the  leg 
and  the  piece  which  connects  the  two  disks,  B  and  C.  The  disks 
are  lined  with  two  or  three  thicknesses  of  blanket,  easily  renewed, 
when  necessary,  with  a  needle  and  thread.  These  braces  are  so 
cheap  and  easily  knocked  together  that  it  is  nothing  to  apply 
new  and  larger  ones,  using  heavier  material  for  the  shank  as  the 
child  grows.  In  general,  three  sizes  will  be  enough,  the  shanks 
being  12  gauge,  f  in.  wide ;  14  gauge,  i  in.  wide  ;  and  16  gauge, 
I  in.  wide.  The  disks  are  conveniently  made  from  22  gauge, 
\\  in.  wide.  The  rivets  are  copper  belt  rivets,  No.  13.  A  lip 
turned   on   the  edges  of  the  disks,   with  the  flat  pliers,  gives 


Fig.  453. 


Fig.  454. 


Fig.  455. 


Fig.  456. 


Fig.  457. 


Fig.  458. 


The  Judson  club-foot  splint  and  its  application. 


stiffness  to  the  thin  brass  and  protects  the  skin  from  the  rough 
edge.  If  more  easily  obtained,  tin  disks,  light  bars  of  iron  or 
steel,  and  ordinary  iron  rivets  would  doubtless  answer. 

"  The  brace  is  applied  with  three  strips  of  adhesive  plaster. 
The  upper  and  lower  pieces,  F  and  G,  Fig.  454,  are  simply  to 
keep  the  apparatus  in  place,  which  they  do  effectively  if  ordinary 
gum  plaster  i.s  used  ;  while  by  drawing  the  middle  strip,  E,  tightly 
over  the  shield,  and  straightening  the  brace  from  time  to  time, 
the  deformity  is  gradually  and  gently  reduced.  At  each  reappli- 
cation  the  brace  is  made  a  little  straighter  than  the  foot  at  that 


756  ORTHOPEDIC  SURGERY. 

stage.  This  may  readily  be  done  by  the  hands,  and  then  the 
adhesive  strip  is  to  be  tightened  over  the  shield  until  the  shape  of 
the  foot  agrees  with  that  of  the  brace.  After  a  few  days  the  brace 
is  to  be  made  still  straighter  and  again  reapplied,  and  made  tight 
until  another  point  of  improvement  is  gained.  The  brace  is  applied 
very  crooked  at  the  beginning  of  treatment,  as  in  Figs.  453  and 
454,  and  is  straightened  from  time  to  time,  and  a  longer  brace 
applied  as  the  deformity  is  reduced  and  the  patient  grows.  It 
should  be  removed  every  week  or  two  weeks,  and  an  interval 
of  a  few  days  allowed  for  freedom  from  the  brace,  when  the 
mother  is  advised  to  manipulate  the  foot  constantly,  using  as 
much  force  as  she  will  in  the  direction  of  symmetry.  Manipu- 
lating the  foot  during  these  intervals  is  of  great  importance,  as 
cases  have  occurred  in  which  varus  and  equinus  have  been  entirely 
overcome  by  the  mother's  hand  alone. 

"  By  this  simple  and  prosy  treatment,  carried  out  systematically 
and  without  haste,  or  violence,  or  pain,  the  foot,  unless  it  is  a 
frightful  exception,  may  with  certainty  be  changed  from  varus  to 
valgus.  At  the  same  time  the  tendo  Achillis  is  lengthened  until 
the  position  of  the  foot  is  near  the  normal,  or  at  right  angles 
with  the  leg,  as  the  result  of  manipulation  and  giving  the  brace 
from  time  to  time  a  partly  anteroposterior  action.  Figs.  453  and 
454  show  approximately  the  shape  of  the  brace  at  the  beginning 
of  treatment ;  Figs.  455  and  456  when  the  varus  is  reduced,  and 
Figs.  457  and  458  when  valgus  has  taken  the  place  of  varus. 
The  foot,  in  this  latter  stage,  may  not  hold  itself  valgus  when 
left  to  itself,  but  with  almost  no  force  and  with  one  finger  it  may 
be  pushed  into  valgus." 

When  the  varus  deformity  is  reduced  the  equinus  is  gradually 
corrected  by  carrying  the  splint  behind  the  internal  malleolus ; 
and,  finally,  if  necessary,  direct  upward  pressure  may  be  applied 
by  lengthening  the  brace  and  applying  it  to  the  posterior  aspect 
of  the  foot  and  leg.  It  may  be  noted  that  manipulation  and 
stretching  the  contracted  parts  when  the  brace  is  removed  is  of 
much  importance  in  the  correction  of  deformity  by  this  or  other 
means.  Splints  of  wood,  tin,  felt,  and  the  like  may  be  employed, 
but  they  present  no  particular  advantage  over  that  which  has 
been  described. 

Tenotomy.  The  equinus  has  been  spoken  of  as  the  secondary 
deformity,  but  its  complete  correction  is  often  more  difficult  than 
that  of  varus.  The  mechanical  stretching  of  the  contracted  parts 
by  means  of  the  plaster-of-Paris  bandage  or  the  brace  is  often 


DEFORMITIES  OF  THE  FOOT.  757 

accomplished  with  ease ;  but  in  many  instances  time  will  be 
gained,  after  the  foot  has  been  forced  into  the  position  of  equino- 
valgus,  by  the  division  of  the  tendo  Achillis,  which  is  the  most 
resistant  of  the  shortened  tissues.  After  division  of  the  tendon 
it  is  often  necessary  to  use  considerable  force  to  stretch  the  other 
contracted  parts,  and  to  force  the  foot  up  to  the  limit  of  normal 
dorsal  flexion,  which  is  the  object  of  the  operation.  Occasionally 
the  obstacle  seems  to  be  in  the  posterior  ligament  of  the  ankle, 
and  it  is  sometimes  of  service  to  reinsert  the  knife  and  to  divide 
this  structure,  in  part  at  least,  so  that  it  will  give  way  under 
manipulation.  When  the  foot  has  been  forced  into  the  posi- 
tion of  overcorrection  it  is  fixed  in  a  plaster  bandage,  which 
is  allowed  to  remain  for  several  weeks,  until  the  interval  be- 
tween the  separated  ends  of  the  tendon  is  filled  in  with  the  new 
tissue. 

In  many  instances  the  leg  is  rotated  inward  upon  the  thigh, 
and  the  habitual  attitude  is  accompanied  by  accommodative 
changes  in  the  ligaments  of  the  knee-joint.  During  the  rectifi- 
cation of  the  club-foot  this  secondary  distortion  may  be,  in  part 
at  least,  corrected  by  forcible  manual  rotation  of  the  leg  outward 
on  the  thigh  several  times  daily. 

Recapitulation.  The  management  of  the  first  stage  of  the 
treatment  of  infantile  club-foot  is,  then :  manipulation  of  the 
foot  by  the  nurse  from  birth  until  systematic  rectification  can  be 
begun  ;  mechanical  correction,  first  of  the  varus  and  then  of  the 
equinus  deformity,  terminating  with  a  period  of  retention  in  the 
overcorrected  position  (calcaneovalgus).  Division  of  tendons, 
other  than  the  tendo  Achillis,  is  not  often  necessary.  The  time 
required  for  the  completion  of  the  first  stage  of  the  treatment,  or 
overcorrection  of  deformity,  should  not,  under  favorable  condi- 
tions, exceed  three  months. 

The  rapid  correction  of  deformity  in  the  manner  described, 
begun  as  early  as  possible  and  accomplished  as  quickly  as  pos- 
sible, cannot  be  too  strongly  urged.  In  the  first  months  of  life 
the  tissues  are  not  resistant,  the  bones  are  practically  entirely 
cartilaginous,  and  when  the  foot  in  its  external  appearance  is 
rectified  the  rapid  growth  in  the  first  months  of  life  will  change 
the  internal  structure  to  conform  to  the  normal  conditions.  The 
fear  of  atroi)hy,  compression,  or  other  harm  from  the  temporary 
fixation  necessary  during  rectification  is  groundless,  and,  in 
fact,  exercise,  so-called,  except  in  the  direction  opposed  to 
deformity,  is  harmful  rather  than  beneficial. 


758  OB THOPEDIG  SUBOEB  Y. 

Correction  of  deformity  may  be  accomplished  by  holding  the 
foot  in  an  improved  position  by  strips  of  adhesive  plaster,  or  by 
the  elastic  traction  of  rubber  bands  attached  to  the  leg  and  foot. 
As  compared  with  the  ease,  rapidity,  and  certainty  of  correction 
by  means  of  the  plaster  bandage  such  methods  are  uncertain  and 
ineffective,  and  they  will  not  therefore  be  described  in  detail. 

The  Second  Stage  of  Treatment.  Support  and  Restoration  of 
Function.  When  the  deformed  foot  has  been  corrected,  in  the 
sense  that  all  normal  motions  can  be  carried  out  by  passive  force, 
the  first  and  most  difficult  part  of  the  treatment  will  have  been 
completed,  and,  in  some  instances,  the  deformity  is  actually  cured. 
Such  a  result  is  unusual,  however,  for  although  the  foot  may  be 
normal  in  appearance,  its  muscular  balance  has  not  been  restored. 
This  is  shown  by  the  fact  that  when  support  is  removed  the  foot 
usually  hangs  downward  and  inward,  and  there  is  little  apparent 
power  in  the  dorsiflexors  and  abductors  to  draw  it  upward  and 
outward.  If  at  this  stage  treatment  were  abandoned  the  defor- 
mity would  almost  invariably  recur,  at  least  in  part.  For  this 
reason  the  foot  must  be  supported  in  proper  position  until  the 
slack  of  the  lengthened  tissues  has  been  taken  up  by  development 
in  the  normal  attitude,  aided  by  massage  and  stimulation  of  the 
muscles.  Practically,  support  is  always  necessary  until  the  child 
has  begun  to  walk. 

The  Retention  Brace.  The  form  of  retention  brace  will 
vary  somewhat  according  to  the  indications  of  the  individual  case. 
The  object  is  to  hold  the  foot  in  what  is  called  the  overcorrected 
attitude — that  is,  dorsiflexion  and  eversion.  This  may  be  accom- 
plished by  splints  of  pasteboard,  leather,  tin,  and  the  like  ;  but  a 
light  metal  brace  provided  with  a  sole  plate  and  upright,  as 
shown  in  Figs.  483  and  484,  is  preferable.  The  best  support  is 
the  Taylor  brace,  the  invention  of  Dr.  C  F.  Taylor,  of  New 
York  (Fig.  459).  This  consists  essentially  of  a  light  upright 
that  extends  along  the  inner  side  of  the  leg  to  the  knee,  and  a 
thin  steel  foot  plate  of  the  exact  size  of  the  sole,  with  an  upright 
flange  on  the  inner  side,  rising  to  a  point  just  above  the  dorsal 
surface  of  the  foot,  against  which  the  foot  is  pressed  closely,  so 
that  recurrence  of  the  varus  deformity  is  prevented.  The  joint 
at  the  ankle  is  provided  with  a  catch  that  prevents  plantar  flexion, 
but  allows  dorsiflexion.  By  bending  the  upright  and  the  sole 
plate  the  foot  may  be  held  in  slight  abduction  and  eversion. 
The  apparatus  is  applied  with  straps,  as  illustrated,  and,  if  neces- 
sary, its  position  is  further  fixed  by  a  band  of  adhesive  plaster. 


DEFORMITIES  OF  THE  FOOT. 


759 


applied  on  the  inner  side  of  the   leg  to  hold  the  heel    firmly 
against  the  foot  plate.     The  foot  is  thus  held  constantly  at  a 


Fig.  459. 


The  Taylor  club-foot  brace. 


Fig.  460. 


Fig.  4*51. 


Taylor  club-foot  brace,  showing  the  method  of  application  and  attachment. 


760 


ORTHOPEDIC  S UBOEB  Y. 


right  angle  to  the  leg,  or,  better,  in  the  early  stage  of  treatment, 
in  an  attitude  of  dorsifiexion  and  valgus.  Occasionally,  after 
complete  rectification  of  the  deformity,  the  foot  still  turns  in.  In 
most  instances  this  is  due  to  an  inward  rotation  of  the  tibia  on 
the  femur  at  the  knee-joint,  but  in  some  cases  it  is  caused  by  a 
spiral  twist  of  the  tibia  itself.  In  order  to  correct  this  secondary 
deformity  an  extension  of  the  upright  of  the  brace  is  carried 
beneath  the  leg,  provided  with  a  joint  at  the  knee,  and  is  extended 
up  the  outer  side  of  the  thigh.  At  the  hip  it  is  attached  by  a 
free  joint  to  a  padded  pelvic  band  of  light  steel  (Fig.  470).  The 
band  holds  the  upright  in  the  proper  relation  to  the  thigh ;  thus. 


Fig.  462. 


Fig.  463. 


The  Taylor  club-foot  brace,  showing  the  adhesive  plaster,  by  means  of  which  the  heel  Is 
held  down,  and  the  method  of  attachment.  This  brace  may  be  used  to  correct  deformity  as 
well  as  to  retain  the  foot  in  proper  position,  as  is  illustrated  by  these  figures.  As  a  retention 
apparatus  the  foot  plate  should  be  held  at  a  right  angle  to  the  upright  by  the  stop-joint 
shown  in  Fig.  459. 

by  twisting  the  part  below  the  knee  the  foot  can  be  rotated  out- 
ward to  the  desired  degree.  In  less  marked  cases  the  retention 
bands  used  for  pigeon-toe  may  be  employed  (Fig.  426). 

Methodical  Manual  Correction.  Several  times  during 
the  day  the  brace  should  be  removed  in  order  that  the  foot  may 
be  thoroughly  massaged  and  forcibly  turned,  first  toward  valgus 
— that  is,  outward  at  the  mediotarsal  joint — so  that  the  inner 
border  is  made  convex,  and  then  to  the  extreme  limit  of  dorsi- 
fiexion and  abduction.     If  the  leg  is  rotated  inward  it  is  forcibly 


DEFORMITIES  OF  THE  FOOT.  761 

rotated  outward  on  the  femur.  Even  if  the  tibia  is  actually 
twisted  on  its  long  axis,  the  influence  of  the  brace  and  forcible 
manipulation  will  usually  correct  the  deformity.  Active  contrac- 
tion of  the  weak  muscles  may  be  induced  by  tickling  the  sole  of 
the  foot  or  by  the  use  of  electricity,  and,  finally,  the  entire  limb 
should  be  thoroughly  massaged  before  the  brace  is  reapplied. 

When  the  deformity  shows  no  tendency  to  recur  the  brace  may 
be  removed  for  a  part  of  the  day  ;  later  it  is  used  only  at  night ; 
and,  finally,  it  may  be  discarded  if  the  child  walks  normally. 
But  it  is  best  to  continue  the  daily  manipulation,  more  particu- 
larly the  systematic  stretching  or  overcorrection  of  the  foot,  for  a 
long  time.  Thus  one  may  assure  one's  self  that  there  is  no 
tendency  toward  deformity,  of  which  the  first  symptom  is  always 
a  slight  limitation  of  dorsal  flexion  and  of  abduction. 

In  many  instances  the  deformity  may  have  been  so  thoroughly 
overcorrected  by  the  plaster-of -Paris  bandage  or  by  the  brace, 
and  the  after-treatment  of  massage  and  stretching  may  have  been 
so  efficiently  applied  by  the  nurse  or  parent,  that  the  retention 
brace  may  be  unnecessary.  On  the  other  hand,  the  inclination 
toward  deformity  may  be  so  marked  that  a  brace  may  be  neces- 
sary to  hold  the  foot  in  slight  abduction  and  valgus  for  a  year 
or  longer.  In  other  cases  the  use  of  a  light  brace  to  hold  the 
foot  in  the  overcorrected  position  during  the  night  is  alone  required. 
These  are  points  to  be  decided  by  the  circumstances  in  each  case. 
The  period  of  observation  and  supervision  is  included  in  the  final 
stage  of  the  treatment. 

Third  Stage  of  Treatment.  Supervision.  During  this  period 
the  attitudes  of  the  limb  and  foot  of  the  walking  child  must  be 
carefully  watched,  and  particularly  the  signs  of  wear  on  the  sole 
of  the  shoe.  If  it  shows  greater  wear  on  the  outer  side  than  is 
usual  it  is  an  indication  that  the  weight  does  not  fall  directly  on 
the  centre  of  the  foot,  and  that  there  is,  therefore,  a  tendency 
toward  deformity.  This  must  be  counteracted  by  making  the 
sole  thicker  on  the  outer  side  or  slightly  wedge-shaped,  so  that 
the  weight  may  be  deflected  toward  the  inner  border. 

This  third  period  of  treatment,  or,  rather,  of  oversight  of  the 
functional  use  of  the  foot,  must  be  continued  indefinitely.  In 
fact,  it  is  the  quality  of  this  final  supervision  that  decides  in  most 
instances  whether  the  ultimate  outcome  is  to  be  what  is  called  a 
satisfactory  residt  or  a  perfect  anatomical  and  functional  cure. 

The  Treatment  of  Neglected  Club-foot.  The  treatment  of 
club-foot,   under   what  may  l)e  called   the  proper  conditions,  as 


762  ORTHOPEDIC  SURGERY. 

outlined  in  the  preceding  pages,  applies  practically  to  all  cases 
before  the  completion  of  the  first  year  of  life,  and  mechanical 
rectification  may  be  successfully  employed  in  cases  far  beyond 
this  limit  of  age.  As  a  rule,  however,  when  the  patient  has 
walked  for  any  length  of  time,  the  resistance  of  the  tissues  has 
increased  to  such  an  extent  that  more  rapid  and  effective  treat- 
ment is  indicated.  The  investigations  of  Wolff  have  shown  that 
the  internal  structure  of  the  bones  corresponds  to  their  external 
contour,  and  that  the  structure  and  contour  are  adaptations  to 
functional  use.  This  internal  structure  is  not,  however,  perma- 
nent, but  is  readily  transformed  to  conform  to  changes  in  form 
or  function.  If,  then,  the  external  contour  of  the  club-foot  were 
suddenly  reversed,  and  if  the  foot  were  used  in  this  new  attitude, 
a  transformation  of  the  internal  structure  of  the  bones  and  at 
the  same  time  of  their  shape  would  begin  at  once.  This  would 
continue  until  both  structure  and  shape  had  become  adapted  to 
habitual  function.  It  is  upon  this  natural  power  of  transforma- 
tion that  one  depends  for  the  final  and  complete  change  of  the 
distorted  bones  to  the  normal ;  and  what  is  true  of  a  resistant 
structure  like  bone  is  equally  true  of  the  other  constituents  of  the 
deformed  foot. 

Age  as  Influencing  Treatment.  There  is,  then,  this  important 
difference  between  the  indications  for  treatment  in  infancy  and 
in  childhood.  In  the  first  instance  the  foot  has  no  essential 
function  ;  in  the  second  the  weight  of  the  body  and  habitual  use 
tend  to  confirm  and  to  increase  the  deformity.  If  walking  is 
permitted  during  the  process  of  rectification  of  the  foot  it  must 
necessarily  retard  its  progress.  As  a  general  principle  of  treat- 
ment, functional  use  should  not  be  permitted,  therefore,  until  the 
weight  of  the  body  may  aid  rather  than  retard  the  correction  of 
deformity.  The  great  numbers  of  complicated  and  cumbersome 
machines  that  are  shown  in  the  older  text-books  were  designed 
for  the  ambulatory  treatment  of  club-foot ;  and  admitting  that 
such  apparatus  may  be  efficacious  in  the  hands  of  one  skilled  in 
its  use,  yet  under  ordinary  conditions  treatment  by  such  means 
simply  serves  to  fix  rather  than  to  correct  the  deformity.  The 
most  important  function  of  the  brace,  aside  from  its  use  as  a 
correcting  appliance  in  early  infancy,  is  to  support  the  foot  after 
deformity  has  been  corrected  and  to  guide  it  in  its  functional  use 
until  its  normal  strength  has  been  regained.  And  while  rectifi- 
cation of  deformity,  even  in  adolescence,  by  simple  mechanical 
means  alone  is  possible,  yet  only  in  exceptional  cases  would  one 


DEFORMITIES  OF  THE  FOOT. 


763 


be  justified  in  selecting  a  tedious  and  uncertain  treatment  which 
offers  practically  no  advantage  over  more  rapid  methods. 

The  Rapid  Correction  of  Deformity.  The  principles  on  which 
operative  treatment  should  be  conducted  are  the  same  that  govern 
mechanical  treatment.  Thus,  the  deformed  foot  must  be  over- 
corrected,  and  it  must  be  held  in  the  overcorrected  position  until 
the  immediate  tendency  toward  deformity  has  been  overcome. 
It  must  then  be  supported  until  the  process  of  transformation  of 
its  internal  structure  is  completed  and  until  the  balance  of  mus- 
cular power  has  been  regained.     No  surgical  operation,  however 


Fig.  464. 


Reduction  of  the  varus  deformity.    (Lorenz, 


radical,  can  be,  in  childhood  at  least,  curative  by  itself  alone. 
Operative  procedures  are  undertaken  simply  for  the  purpose  of 
accomplishing  the  primary  overcorrection,  and  the  operation 
by  which  this  object  can  be  attained  with  the  least  interference 
with  the  structure  of  the  foot  should  be  selected.  Such  an 
operation  is  what  may  be  called  forcible  manual  correction. 

Forcible  Manual  Correction.  The  patient  having  been,  ansps- 
thctized,  one  first  attempts  to  correct  the  sharp  inward  twist  at 
the  mediotarsal  joint.  Supposing  the  left  foot  to  be  deformed, 
one  grasps  the  heel  with  the  right  hand   in  such  a  manner  that 


764 


ORTHOPEDIC  S  UB  GEB  Y. 


the  projection  or  muscular  part  of  the  palm  lies  on  the  outer 
aspect  of  the  foot  against  the  most  prominent  part  of  its  outer 
border,  which  is  at  the  junction  of  the  os  calcis  and  cuboid  bones. 
This  hand  serves  as  a  fulcrum  over  which  the  inverted  foot  may 
be  bent.  The  forefoot  is  then  grasped  firmly  by  the  left  hand, 
and  one  begins  a  series  of  outward  twists  over  the  fulcrum  of  the 
opposing  palm,  gently  at  first,  with  alternate  relaxation  of  pressure, 
but  with  gradually  increasing  force  as  the  resistant  tissues  stretch 
under  the  tension. 

Fig.  465. 


Flattening  the  sole.    (Lorenz.) 


If  greater  force  is  required,  a  triangular  block  of  wood,  well 
padded,  may  be  used  as  the  fulcrum  (Fig.  464),  one  hand  pressing 
on  the  heel  and  the  other  on  the  forefoot ;  but  there  is  a  great 
advantage  in  using  nothing  but  the  hands,  because  one  feels  sure 
that  no  injurious  force  is  likely  to  be  exerted.  Under  this  steady 
manipulation  the  foot  soon  loses  its  rigidity  and  its  elastic  recoil 
toward  deformity  ;  it  becomes  so  limp  that  with  two  fingers  one 
cannot  only  hold  the  sole  straight,  but  can  push  it  or  bend  it 


DEFORMITIES  OF  THE  FOOT. 


765 


outward.      Thus  the  first  stage  of  the  methodical  correction  has 
been  accomplished. 

One  then  turns  his  attention  to  the  supination  or  inversion  of 
the  sole,  which  makes  the  outer  border  of  the  foot  lower  than 
the  inner  border.  The  leg  is  grasped  firmly  near  the  ankle  with 
the  left  hand,  and  with  the  right  the  foot  is  forcibly  twisted  in  a 
direction  downward,  outward,  and  upward,  over  and  over  again, 
with  steadily  increasing  force  as  the  tissues  slowly  yield,  until  it 
may  be  forced  into  a  position  of  extreme  abduction,  so  that  the 

Fig.  466. 


Reduction  of  the  equinus  deformity.    (Lorenz.) 


sole  may  be  made  to  look  outward  and  downward — the  reverse  of 
the  former  attitude  (Fig.  384). 

One  next  stretches  the  contracted  plantar  fascia  and  reduces 
the  cavus  which  is  usually  present  by  forcing  the  forefoot  toward 
dorsiflexion,  against  the  resistance  of  the  contracted  tendo  Achillis, 
until  the  sole  is  made  perfectly  flat  (Fig.  465).  Finally,  the 
fourth,  and  often  the  most  difficult  part  of  the  rectification — that 
of  forcing  the  displaced  astragalus  into  its  proper  position  between 
the  malleoli — is  attempted.  To  accomplish  this  the  tendo  Achillis 
is  first  divided  subcutaneously,  and,  if  necessary,  the  posterior 


766  ORTHOPEDIC  S  UB GEB  Y. 

ligament  of  the  ankle  is  also  divided  at  the  same  time.  The 
patient  is  then  turned  upon  his  face  so  that  with  the  knee  resting 
on  the  table  the  leg  is  held  upright.  This  allows  one  to  hook  the 
fingers  about  the  extremity  of  the  os  calcis,  while  the  hand  and 
arm,  lying  along  the  sole  of  the  foot,  may  be  used  as  a  lever  to 
force  it  toward  dorsal  flexion  as  the  os  calcis  is  drawn  down- 
ward. In  this  manner  forcible  stretching  is  continued  until  the 
dorsum  of  the  foot  can  be  brought  almost  into  apposition  with 
the  crest  of  the  tibia.     When  the  operation  has  been  completed 

Fig.  467. 


Untreated  club-foot,  showing  the  secondary  knock -knees.    (See  Fig.  468.) 

the  foot  should  be  perfectly  limp.  It  is  usually  somewhat  con- 
gested from  the  pressure  of  the  fingers,  but  it  is  warm  and  the 
circulation  is  unimpaired. 

One  may  assume  that  in  the  change  that  has  taken  place  from 
rigid  deformity  to  a  limp  foot  that  can  be  moulded  into  the 
desired  shape  the  component  parts  of  the  deformed  foot  must 
have  been  subjected  to  considerable  violence ;  that  ligaments  and 
muscles  must  have  been  stretched  and,  it  may  be,  ruptured ; 
that  new  surfaces  are  now  apposed  to  one  another  in  the  articu- 
lations, and  that  the  bones  have  been  forced  into  approximately 


DEFORMITIES  OF  THE  FOOT. 


767 


normal  position.  This  method  of  treatment  has  a  great  advantage 
over  the  ordinary  operative  treatment  in  that  the  entire  foot  par- 
ticipates in  the  correction  instead  of  a  limited  portion,  as  when, 
for  example,  bone  is  removed  by  cuneiform  osteotomy.  It  has 
a  second  and  almost  equally  important  advantage  in  that  the 
immediate  use  of  the  corrected  and  yieldiug  foot  is  possible  in 
the  place  of  the  necessary  rest  that  must  follow  cutting  opera- 
tions. For  these  reasons  forcible  massage  should  be  the  operation 
of  choice,  and  preliminary,  at  least,  to  more  severe  procedures 


Fig.  469. 


After  forcible  correction.    Compare  with 
Fig.  467. 


The  attitude  of  overcorrectiou,  in  which 
the  feet  are  fixed  after  the  operative  treat- 
ment, the  plaster  bandage  extending  only 
to  the  knees. 


in  the  treatment  of  resistant  club-foot  in  childhood.  The  only 
disadvantage  of  the  operation  is  the  actual  labor  which  it  neces- 
sitates on  the  part  of  the  surgeon,  usually  twenty  minutes  or 
more  of  rather  exhausting  work. 

The  foot  must  now  be  fixed  by  a  plaster  bandage  in  an  over- 
corrected  position.  It  is  first  evenly  covered  with  a  layer  of 
cotton  and  a  broad  bandage  of  canton  flannel,  and  while  it  is  held 
by  the  assistant  the  plaster  bandages  are  ai)plicd  from  the  tips  of 
the  toes  to  the  upper  part  of  the  thigh.     It  is  important  that  the 


768  ORTHOPEDIC  SURGERY. 

toes  should  not  project  beyond  the  bandage  because  of  the  swell- 
ing that  sometimes  follows.  It  is  important,  also,  that  the  foot 
should  be  held  in  the  proper  position  while  the  bandage  is  harden- 
ing, and  that  it  should  not  be  manipulated  to  any  extent  after 
the  bandage  is  applied,  in  order  that  no  rigid  wrinkle  may  press 
against  the  skin.  The  bandage  is  applied  above  the  knee  in 
order  that  the  tibia  may  be  rotated  outward  to  its  normal  position 
and  held  there,  and  because  more  effective  fixation  may  be  assured 
and  greater  pressure  exerted  on  the  foot  in  walking.  To  utilize 
this  pressure  to  better  advantage  the  bandage  should  be  made 
very  thick  beneath  the  sole,  and  a  thin  foot  plate  of  wood  may 
be  incorporated  in  the  plaster  if  due  care  is  taken  to  prevent 
pressure  on  sensitive  points.  When  the  bandage  is  applied  the 
position  of  the  foot  should  be  that  of  overcorrection  of  deformity, 
flexed  beyond  the  right  angle,  twisted  far  outward,  and  the  outer 
border  should  be  elevated  considerably  beyond  the  level  of  the 
inner  border  (Fig.  468). 

One  would  suppose,  after  using  the  force  that  has  been  neces- 
sarily applied,  that  much  pain  and  swelling  would  follow.  This 
is,  however,  not  usually  the  case.  Often,  on  the  following  day, 
the  patients  are  able  to  stand  upon  the  foot,  and  always  within 
the  first  week  if  the  bandage  has  been  properly  applied.  The 
pain  following  this  operation  is  far  more  often  caused  by  pressure 
of  an  ill-fitting  bandage  than  by  the  violence  that  has  been  used. 
Thus  one  should  be  careful  to  remove  sections  of  the  bandage 
if  it  appears  to  cause  undue  discomfort.  These  points  are  usually 
the  front  of  the  ankle,  the  back  of  the  heel,  and  the  inner  border 
of  the  great  toe. 

The  Importance  of  Functional  Use.  The  immediate  use  of  the 
foot  is  encouraged,  in  order  that  the  weight  of  the  body  falling 
on  its  yielding  structure  may  still  further  correct  the  deformity. 
Although  only  the  heel  and  inner  border  bear  weight  directly, 
yet  the  pressure  of  the  plaster  sole  on  the  parts  that  do  not  come 
in  contact  with  the  floor  is  usually  sufficient  to  mould  the  foot 
into  its  proper  shape.  If  greater  pressure  is  thought  to  be  neces- 
sary, wedges  of  wood  or  cork  may  be  attached  to  the  sole  of  the 
plaster  bandage,  so  that  all  parts  may  bear  weight  equally.  The 
bandage  is  covered  by  a  stocking  ;  a  slipper  may  be  worn  indoors 
and  an  ordinary  overshoe  for  street  wear. 

The  first  bandage  should  be  removed  at  the  end  of  about  four 
weeks,  as  it  will  have  become  loose.  The  foot  will  then  be  found 
to  be  extremely  flexible,  and  by  an  enthusiast  it  might  be  consid- 


DEFORMITIES  OF  THE  FOOT.  769 

ered  cured ;  but  knowledge  of  its  previous  condition  should 
make  it  evident  that  a  much  longer  time  will  be  necessary  to 
allow  for  its  consolidation  in  the  new  position.  At  this  time 
almost  no  evidence  of  the  operation  remains  except,  it  may  be, 
slight  discoloration  of  the  skin.  The  foot  is  again  held  as  far  as 
possible  in  the  overcorrected  position  and  another  plaster  bandage 
is  applied,  usually  as  far  as  the  knee  only.  This  is  allowed  to 
remain  for  from  six  weeks  to  six  months,  it  being  apparent,  of 
course,  that  the  longer  the  foot  is  fixed  in  the  overcorrected 
position  the  less  danger  of  subsequent  relapse.  The  patient  uses 
the  foot  constantly  and  is  drilled  in  the  proper  method  of  walk- 
ing, so  that  the  muscles  of  the  limbs  may  become  accustomed  to 
the  new  and  normal  attitudes. 

In  most  instances  the  plaster  bandage  is  replaced,  at  the  end 
of  about  three  months,  by  a  brace  to  be  worn  inside  the  shoe, 
usually  of  the  simplest  description  (Fig.  484),  consisting  of  an 
upright  bar  with  a  calf  band,  attached  to  a  steel  sole  plate  by  a 
joint  that  will  permit  dorsal  flexion  but  checks  extension  at  a 
right  angle.  This  is  applied  because  the  dorsal  flexors,  after 
years  of  disuse,  only  slowly  recover  sufficient  power  to  resist  the 
action  of  the  opposing  group  and  the  force  of  gravity. 

The  second  stage  of  the  treatment  is  now  begun.  This  may 
be  divided  into  a  period  of  active  treatment  and  one  of  super- 
vision. The  first,  or  treatment  stage,  consists  in  massage  of  the 
entire  leg  and  of  the  foot  to  stimulate  the  growth  of  the  atrophied 
muscles,  and  methodical  manipulation  of  the  foot  several  times 
a  day.  The  important  point  in  this  manipulation  is  to  force  the 
foot  with  the  hand  to  the  extreme  of  the  range  of  motions  possible 
immediately  after  the  operation,  viz.,  eversion,  abduction,  and 
dorsal  flexion,  in  the  same  order  as  at  the  time  of  operation. 
At  the  same  time  the  patient  attempts  voluntarily  to  carry  out 
these  motions  by  his  own  muscles,  the  power  being  supplied  by 
the  hand  of  the  manipulator.  Slowly  the  muscles  gain  in 
strength  and  ability,  and  when  normal  muscular  power  and  bal- 
ance have  been  regained  the  patient  is  practically  cured.  But 
for  a  long  period  supervision  of  the  patient's  attitude,  of  the 
manner  of  using  the  foot,  of  the  wear  of  the  sole  of  the  shoe 
and  the  like  must  be  exercised  if  one  aims  to  restore  its  normal 
appearance  and  function. 

One  cannot  exaggerate  the  importance  of  this  after-treatment 
and  of  supervision,  at  least,  on  the  part  of  the  surgeon.  The 
active  treatment  may  often  be  left  to  the  parents.     But  constant 

49 


770 


ORTHOPEDIC  SURGERY. 


oversight  is  necessary  to  make  this  after-treatment,  which  seems 
so  commonplace  and  simple,  effective,  and  to  assure  one's  self 
that  the  range  of  motion  regained  by  the  operation  does  not 
gradually  become  more  and  more  restricted,  even  though  the 
contour  of  the  foot  appears  to  be  normal. 

Forcible  manual  correction  may  be  employed  with  advantage 
from  the  second  to  the  tenth  year,  although  the  limits  may  be 

extended  in  either  direction   in 
Fio-  470.  special  cases.     In  this  operation, 

as  described,  the  tendo  i^chillis 
is  the  only  structure  divided. 
There  is  no  particular  objection 
to  subcutaneous  division  of  other 
tendons  or  ligaments  in  connec- 
tion with  forcible  manual  correc- 
tion ;  but  for  such  prolonged 
manipulation  it  is  much  better  if 
the  skin,  which  itself  must  be 
stretched,  is  unbroken  and  dry 
rather  than  moist  from  the  bleed- 
ing from  punctured  wounds.  For 
this  reason  it  is  well  to  correct 
the  deformity  without  extensive 
tenotomy  if  possible.' 

Secondary  Deformities.  In  cases 
such  as  have  been  described  sec- 
ondary distortions  of  the  limb 
are  often  present.  Knock-knee 
rarely  requires  other  treatment 
than  daily  manual  correction  in 
connection  with  the  massage  of 
the  foot  and  leg.  Hyperextension 
at  the  knee  will  correct  itself 
during  the  treatment  of  the  foot, 
which,  being  fixed  in  an  attitude 
of  dorsal  flexion,  obliges  the  pa- 
tient to  bend  the  knee  habitually  in  walking.  Inward  rotation 
of  the  leg  upon  the  thigh  is  often  present.    This  may  be  overcome 

1  Forcible  manual  correction  appears  to  have  been  de'scribed  first  by  Delore.  Lorenz  em- 
ploys the  method  supplemented  in  the  older  cases  by  the  use  of  his  osteoclast,  to  the  exclu- 
sion, practically,  of  all  other  treatment.  (Heilung  des  Klumpfusses  durch  das  modellirende 
Redressement,  Wiener  Klinik,  November,  1895.)  For  this  reason  it  is  sometimes  called  the 
Lorenz  treatment.  The  method  that  has  been  described  has  been  employed  by  the  author 
for  many  years. 


The  Taylor  club-foot  brace,  with  pelvic 
band,  to  prevent  rotation  of  the  leg.  The 
brace  is  shown  before  the  covering  and 
straps  are  applied. 


DEFORMITIES  OF  THE  FOOT.  771 

by  methodical  manipulatiou  and  by  the  use  of  a  brace  attached  to 
a  pelvic  band  (Fig.  470). 

In  many  instances,  particularly  in  childhood  and  adolescence, 
the  patient  has  so  long  walked  with  exaggerated  outward  rotation 
of  the  femur  that  after  correction  of  the  deformity  no  inward 
rotation  of  the  foot  appears,  even  though  inward  rotation  of  the 
tibia  be  present.  In  other  cases  the  inward  rotation  of  the  foot 
is  caused  by  a  failure  to  completely  replace  the  astragalus  between 
the  malleoli.  Occasionally  the  tibia  is  actually  twisted  on  its 
long  axis,  so  that  an  osteotomy  may  be  required  in  order  to  over- 
come the  deformity. 

Malleotomy.  In  confirmed  club-foot,  of  the  type  under  con- 
sideration, the  chief  obstacle  to  perfect  correction  is  often  the 
astragalus.  This  is  displaced  forward,  downward,  and  inward, 
only  the  posterior  portion  of  its  articulating  surface  being  con- 
tained between  the  malleoli.  Thus  the  space  between  the  two 
bones  may  have  become  insufficient  for  the  anterior  and  wider 
part  of  the  body  of  the  astragalus.  In  such  cases,  even  after 
division  of  the  tendo  Achillis  and  the  posterior  ligament  of  the 
ankle,  dorsal  flexion  still  remains  restricted,  and  examination 
shows  that  the  astragalus  still  projects  as  before,  even  though  the 
foot  has  been  forced  into  a  position  of  apparent  dorsiflexion  and 
abduction.  This  apparent  correction  is  the  result  of  overcorrec- 
tion at  the  mediofcarsal  joint,  of  outward  rotation  of  the  tibia  upon 
the  femur,  and  of  backward  displacement  of  the  fibula. 

In  such  instances  the  malleoli  may  be  separated  from  one 
another  by  dividing  the  ligaments  that  hold  them  in  apposition. 
A  straight  incision  about  two  inches  long  is  made  directly  over 
the  anterior  aspect  of  the  articulation,  the  ligaments  are  divided, 
and  by  inserting  a  thin  chisel  the  bones  are  pried  apart,  while 
the  astragalus  is  replaced  in  the  proper  position.  This  is  usually 
easy  if  the  restraining  tissues  on  the  posterior  part  of  the  ankle 
have  been  divided.  The  wound  is  then  closed  and  the  foot  held  in 
the  overcorrected  position  by  a  plaster  bandage.  Complete  correc- 
tion of  the  varus  deformity  should,  of  course,  precede  this  operation. 

It  might  seem  on  first  consideration  that  if  immediate  correc- 
tion of  deformity  can  he  accomplished  so  easily  in  the  confirmed 
cases  it  should  be  employed  even  in  infancy.  There  are,  how- 
ever, practical  reasons  against  it :  First,  because  the  foot  is  so 
small  that  it  cannot  be  easily  manipulated  ;  second,  because  even 
after  it  is  corrected  it  must  be  supported  until  the  child  begins 
to  walk  ;  and,  third,  because  the  foot  can  be  so  readily  straightened 


772  ORTHOPEDIC  SURGERY. 

without  operation,  which,  even  of  so  slight  a  character,  is  some- 
times the  cause  of  much  anxiety  to  the  parents.  For  these  reasons, 
although  immediate  reduction  of  deformity  is  a  thoroughly  prac- 
tical and  safe  operation,  it  is  usually  postponed  until  a  later  time. 

Subcutaneous  Tenotomy.  The  division  of  tendons  and  other 
tissues  by  the  subcutaneous  method  has  been  mentioned  incident- 
ally, but  as  it  has  so  long  occupied  an  important  and  even  at  one 
time  the  most  important  place  in  the  treatment  of  club-foot,  the 
operation  and  its  effects  may  be  described  somewhat  in  detail. 

Tenotomy,  as  has  been  stated,  is  performed  for  the  purpose  of 
removing  an  obstacle  to  the  correction  and  overcorrection  of 
deformity.  In  the  acquired  or  paralytic  form  of  talipes  one 
or  more  shortened  tendons  may  be  the  chief  obstacles  to  reposi- 
tion ;  but  in  the  congenital  form,  in  which  all  the  tissues  have 
grown  into  deformity,  the  shortened  tendons  are  by  no  means  the 
only  resistant  parts,  and  tenotomy  should  be  considered,  there- 
fore, merely  as  an  incident  in  correction.  In  the  ordinary  treat- 
ment of  infantile  club-foot  tenotomy  may  often  be  dispensed 
with,  and  in  the  great  majority  of  cases  division  of  the  tendo 
Achillis  is  alone  required. 

When  the  tendon  has  been  divided  the  deformity  is  immedi- 
ately overcorrected ;  thus  the  two  extremities  are  separated  to 
the  extent  necessary  to  allow  the  improved  position.  At  the  end 
of  three  weeks  or  more,  or  at  the  time  when  the  first  plaster 
bandage  is  removed,  the  space  will  be  filled  with  new  material, 
and  in  another  month  the  splice,  which  will  be  somewhat  larger 
and  thicker  than  the  normal,  should  be  strong  enough  for  use. 
The  slight  thickening  at  the  site  of  the  operation  may  be  felt  for 
a  year  or  more,  but  for  all  intents  and  purposes  the  new  and 
lengthened  tendon  is  perfectly  normal,  as  is  the  function  of  the 
muscle  of  which  it  is  a  part. 

The  process  of  repair  is  somewhat  as  follows :  Immediately 
after  the  operation  the  space  between  the  divided  ends  of  the 
tendon  is  filled  or  partially  filled  with  blood ;  then  leucocytes 
appear,  which,  with  those  in  the  blood  clot,  serve  as  pabulum 
for  the  plasma  cells  which  migrate  from  between  the  fasciculi  of 
the  tendon  and  from  the  tendon  sheath.  The  fibrin  and  red  cor- 
puscles of  the  clot  are  absorbed ;  the  extremities  of  the  divided 
tendon  soften  and  become  fused  with  the  new  material,  which 
begins  to  take  on  the  form  and  consistency  of  true  tendon  and 
to  separate  itself  from  the  adherent  sheath.  This  new  tendon, 
differs  from  the   normal   structure  in  that  the  fibrous  fasciculi 


DEFORMITIES  OF  THE  FOOT.  773 

are  more  irregular  and  its  substance  is  more  like  scar  tissue,  but 
practically  it  is  perfectly  normal  in  its  appearance  and  function/ 

Since  the  tendon  sheath  serves  an  important  purpose  in  repair, 
it  should  be  disturbed  as  little  as  possible.  For  this,  as  well  as 
for  other  obvious  reasons,  subcutaneous  tenotomy  of  the  tendo 
Achillis,  which  is  so  prominent  and  so  distinct  from  other 
important  parts,  is  to  be  preferred  ;  but  if  more  extensive  division 
of  other  tendons  is  required  the  open  operation  is  often  indicated. 

Division  of  the  Tendo  Achillis.  For  this  operation  anaesthesia 
is  usually  required,  preferably  by  means  of  nitrous  oxide  gas  ;  and 
it  is  hardly  necessary  to  state  that  surgical  cleanliness,  even  in 
so  slight  a  procedure,  is  essential. 

The  instrument  should  be  small  and  very  sharp,  so  that  no 
force  is  required  in  the  operation ;  the  blade  should  be  as  long  as 
the  tendon  is  wide.  The  patient  is  turned  upon  the  side  or  to 
the  prone  position,  so  that  the  foot  may  be  held  with  the  heel 
upward  by  the  left  hand.  The  position  and  size  of  the  tendon 
is  ascertained  by  careful  palpation,  and  the  knife  is  then  inserted 
to  its  inner  side,  at  about  the  level  of  the  extremity  of  the 
internal  malleolus.  The  flat  surface  of  the  blade  is  held  parallel 
to  the  tendon,  and  it  is  passed  beneath  it  until  its  point  can  be 
felt  beneath  the  skin  on  the  opposite  side.  The  edge  is  then 
turned  upward  and  the  tendon,  being  made  tense,  is  divided  by  a 
sawing  motion  of  the  knife.  When  the  division  is  complete,  as 
indicated  by  the  separation  of  the  divided  ends,  the  knife  is  with- 
drawn, and  the  minute  opening  in  the  skin,  from  which  there  is 
usually  slight  bleeding,  is  covered  with  a  pledget  of  aseptic 
cotton.  The  foot  is  forced  into  dorsal  flexion  and  is  securely 
fixed  by  a  plaster  bandage.  In  applying  the  dressing  one  should 
take  care  that  no  pressure  is  brought  upon  the  seat  of  operation, 
as  this  might  interfere  with  the  effusion  of  plastic  material.  As 
soon  as  the  discomfort  attending  the  operation  has  subsided  the 
patient  is  encouraged  to  stand  and  to  walk.  Functional  use 
stimulates  the  circulation,  and,  far  from  retarding  repair,  it  is  in  my 
experience  an  important  agent  in  assuring  firm  and  rapid  union. 

The  Open  Method.  The  tendon  may  be  exposed  by  a  long, 
vertical  incision  ;  it  is  then  split  for  a  distance  of  two  or  three 
inches,  and  the  division  is  completed  at  the  upper  and  lower  ends. 
The  two  halves  are  then  allowed  to  slide  by  one  another  until 
the  necessary  elongation  has  been  obtained.  These  are  then 
sutured  to  one  another. 

'  R.  Seggel.    Beitriige  zur  klin.  Chir.,  1003,  Band  xxxvii.  S.  342. 


774  ORTHOPEDIC  SURGERY. 

Theoretically,  this  operation,  which  assures  union  at  a  point 
of  selection,  is  safer  than  the  subcutaneous  method,  in  which  the 
ends  of  the  tendon  are  separated  from  one  another ;  practically, 
it  is  in  this  class  of  cases  less  satisfactory  in  its  results  than  the 
subcutaneous  method. 

Division  of  the  plantar  fascia  is  not  infrequently  necessary, 
and  should  be  performed  subcutaneously.  The  tenotome  is 
inserted  beneath  the  skin  at  about  the  centre  of  the  concavity  to 
one  or  the  other  side  of  the  central  band  of  the  fascia,  which  is 
divided  by  a  sawing  motion  of  the  knife.  The  part  is  put  upon 
the  stretch,  and  other  resisting  bands  to  the  outer  and  inner  side 
are  divided  in  the  same  manner ;  the  cavus  is  then  corrected  by 
manual  or  instruQiental  force.  The  operation,  like  that  upon 
the  tendo  Achillis,  is  practically  free  from  danger. 

Division  of  the  tibialis  anticus  is  not  often  necessary,  as  this 
tendon  offers  little  resistance  to  the  rectification  of  deformity  of 
the  ordinary  type. 

The  tendon  of  the  tibialis  jjosticus  may  be  divided  together 
with  that  of  the  tibialis  anticus  near  the  points  of  attachment. 
If  the  operation  is  required  it  may  be  combined  with  simulta- 
neous section  of  the  calcaneonavicular  ligament,  with  which  are 
blended  the  anterior  part  of  the  deltoid  and  fibres  of  the  anterior 
ligament  of  the  ankle.  According  to  Parker's  directions,  the  foot 
should  be  strongly  abducted  to  make  the  parts  tense.  The  tenotome 
is  entered  directly  in  front  of  the  anterior  border  of  the  internal 
malleolus,  its  cutting  edge  being  turned  forward  between  the  skin 
and  the  ligament.  It  is  then  turned  toward  the  ligament,  and 
the  tissues  are  divided  to  the  bone.  The  blade  is  then  made  to 
enter  the  interval  between  the  astragalus  and  the  scaphoid,  and 
is  carried  downward  and  forward  to  divide  the  inferior  part  of 
the  ligament  and  at  the  same  time  the  tendons  of  the  tibialis  anticus 
and  posticus. 

The  posterior  ligament  of  the  ankle-joint  may  be  divided  or 
sufiiciently  weakened  so  that  it  may  be  ruptured  after  section  of 
the  tendo  Achillis  by  passing  the  knife  directly  downward  in  the 
middle  line  upon  the  upper  border  of  the  astragalus. 

The  Correction  of  Confirmed  Club-foot  by  the  Method  of 

Julius  Wolff. 

Wolff's  treatment  of  club-foot,  as  described  by  Freiberg,  a 
former  assistant  in  his  clinic,  may  be  summarized  as  follows  •} 

1  Medical  News,  October  29, 1892. 


DEFORMITIES  OF  THE  FOOT. 


775 


Fig.  471. 


The  patient  is  anaesthetized,  and  with  the  hands  and  by  the  use 
of  a  moderate  amount  of  force  the  deformity  is  reduced  as  far  as 
possible.  The  foot  is  held  in  the  improved  position  by  means  of 
strips  of  adhesive  plaster  passing  from  the  dorsal  surface  of  the 
inner  border  of  the  foot  under  the  sole  and  up  to  the  outer  aspect 
of  the  leg.  The  leg  and  foot  are  then  covered  with  cotton  from 
the  tuberosity  of  the  tibia  to  the  tips  of  the  toes,  and  a  plaster 
bandage  is  applied.  As  the  plaster  is  hardening  the  position  of 
the  foot  is  still  farther  improved  by  pressing  the  heel  inward  and 
the  forefoot  outward  and  upward.  Two  fenestra  are  cut  in  the 
plaster  at  the  points  of  greatest  pressure — one  over  the  external 
surface  of  the  ankle  and  the  other  over  the 
internal  surface  of  the  great  toe.  If  tenot- 
omy is  considered  necessary  it  is  usually 
performed  as  a  preliminary  operation  several 
days  before  forcible  correction. 

On  the  third  or  fourth  day  after  the  oper- 
ation a  wedge-shaped  section  is  cut  from 
the  bandage  on  the  outer  side  of  the  ankle- 
joint  and  a  linear  division  is  made  about 
the  ankle,  so  that  the  leg  and  the  foot  parts 
of  the  bandage  are  separated  (Fig.  471). 
The  leg  being  held  firmly,  the  foot  is  forced 
outward  and  upward  to  the  extent  that  the 
wedge-shaped  opening  on  the  plaster  will 
allow,  and  the  two  sections  are  then  united 
by  a  covering  of  plaster  bandage.  For  the 
secondary  correction  anaesthesia  is  not  re- 
quired. At  intervals  of  several  days  larger 
wedges  are  removed,  and  the  manipulation 
is  repeated  until  the  patient  stands  with  the  foot  in  a  satisfactory 
attitude ;  that  is,  in  pronation,  abduction,  and  dorsiflexion.  If 
the  deformity  is  extreme  the  bandage  may  be  reapplied  before 
the  correction  is  completed  with  advantage.  One  should  take 
care  that  the  toes  are  not  compressed,  but  lie  on  the  same  plane 
in  normal  relation  to  one  another. 

When  rectification  is  complete  the  plaster  bandage  is  covered 
with  strips  of  pine  shavings,  held  in  place  by  a  crinoline  bandage, 
and  painted  with  carpenter's  glue.  When  this  is  hardened  the 
whole  is  covered  with  a  thin  silicate  bandage  ;  over  this  the  shoe  is 
fitt<;d  and  the  patient  is  (jucouragcd  to  walk.  This  form  of  dress- 
ing is  used  until  the  transformation  of  the  deformed  parts  may 


The  points  at  which  the 
bandage  is  divided  and  the 
wedge  removed.  (Freiberg.) 


776 


ORTHOPEDIC  SUBGEBY. 


be  supposed  to  be  complete,  the  time  varying  with  the  case,  from  a 
few  months  to  a  year.  The  time  required  for  the  primary  cor- 
rection is  from  a  week  to  a  month.  When  the  bandage  is  finally 
removed  massage  and  exercises  are  to  be  employed.^ 

"Wolff 's  treatment  is  an  efficient  means  of  correction,  although 
somewhat  tedious.  It  may  be  more  conveniently  employed  in 
later  childhood  and  adolescence  than  at  an  earlier  age. 


Fig.  472. 


Forcible   Correction  of  Deformity  by  Means  of  Osteoclasts 

and  Wrenches. 

In  place  of  manual  correction  greater  force  may  be  employed 
by  means  of  w^renches  or  osteoclasts  to  overcome  the  deformity. 

There  is  this  important  difference 
between  the  t^vo  procedures : 
force  may  be  applied  by  the  hands 
for  as  long  a  time  as  is  necessary 
without  fear  of  injury,  while  force 
applied  by  a  machine  must  be 
momentary  because  of  the  press- 
ure and  strain  on  the  parts  where 
the  leverage  is  exerted.  Manual 
force  continuously  applied  may 
be  supposed  to  stretch  the  re- 
sistant parts,  and  although  much 
less  power  is  exerted  it  is  really 
more  effective  than  the  sudden 
and  momentary  force  of  the 
wrench  or  osteoclast,  because  it 
may  be  continued  until  the  de- 
formity has  been  overcorrected, 
while  complete  correction  by 
means  of  instruments  may  neces- 
sitate several  operations. 

The  Thomas  Method.  Of 
instrumental  correction  that  by 
means  of  the  Thomas  wrench  is 
one  of  the  simplest  and  most 
efficient.  The  wrenching  may  or  may  not  be  preceded  by  ten- 
otomy, a  point  to  be  decided  by  the  resistance  of  the  parts.     As 


The  Thomas  wrench  as  used  in  the  correc- 
tion of  club-foot. 


1  Ueber  die  Ursachen,  das  Wesen  und  die  Behandlung  des  Klumpfusses. 
Berlin,  190b. 


Julius  WolflF 


DEFORMITIES  OF  THE  FOOT. 


in 


a  rule,  division  of  the  tendo  Achillis  aloue  is  necessary.  The 
instrument  is  a  simple  heavy  monkey-wrench,  of  which  the  jaws 
have  been  replaced  by  two  strong  pins  slightly  bulbous  at  the 
ends  to  keep  the  covers  of  rubber  tubing  from  slipping  off. 

The  wrench  is  applied  to  the  inner  side  of  the  foot  and  screwed 
down  so  that  it  may  "  bite "  and  hold  its  place  firmly,  for  if  it 
slips  it  is  likely  to  abrade  or  tear  the  skin ;  then  with  consider- 
able force  the  foot  is  twisted  outward  and  upward  (Fig.  472). 


Fig.  473. 


Resistant  club-foot  in  later  childhood.    (See  Fig.  474.) 


The  "  keynote "  of  the  operation  is  to  so  wrench  the  foot  that 
it  lo.ses  its  elasticity  and  shows  no  tendency  to  recoil  toward 
deformity.  The  foot  is  then  placed  in  the  best  possible  position, 
and  is  retained  there  by  the  Thomas  foot  splint  or  by  a  plaster 
bandage.  In  certain  instances  one  may  complete  the  rectification 
at  one  operation,  but  this  is  not  usually  attempted,  the  ])rocedure 
being  repeated  at  intervals  of  a  few  days  until  the  deformity  has 
been  overcorrected.  In  very  resistant  eases  eight  or  ten  applica- 
tirms  of  force  may  be  necessary.     When  the  deformity  has  been 


778  ORTHOPEDIC  SURGERY. 

rectified  the  foot  is  held  in  the  overcorrected  position  for  several 
weeks  by  the  splint  or  by  the  plaster  bandage. 

As  a  walking  appliance  a  simple  npright  of  iron  with  a  calf 
band  is  applied  to  the  inner  side  of  the  leg,  from  a  point  just 
below  the  knee  to  the  heel  of  the  shoe  into  which  it  is  inserted, 
as  is  the  Thomas  knock-knee  brace  (Fig.  343).  By  bending  the 
upright  the  foot  may  be  kept  in  slight  valgus,  and  this  position 
is  still  further  assured  by  making  the  outer  side  of  the  sole  of 
the  shoe  thicker  than  the  inner,  so  that  the  weight  falls  upon  the 
inner  border  of  the  foot.  In  many  instances  the  walking  brace 
may  be  dispensed  with  in  the  after-treatment,  but  a  light  brace 
is  usually  worn  to  hold  the  foot  in  the  corrected  position  during 
the  night,  until  the  power  of  the  abductors  and  dorsal  flexors  has 
been  regained.  Massage  aud  manipulation  are  used  in  the  after- 
treatment  in  the  manner  already  described. 

When  properly  applied  the  treatment  is  satisfactory  and  free 
from  danger.  Sloughing  of  the  tissues  caused  by  the  pressure 
of  the  instrument  or  by  the  plaster  bandages  has  been  reported, 
but  such  accidents  have  not  occurred  in  the  extensive  practice  of 
Thomas  and  Jones. 

Correction  by  Means  of  the  Osteoclast.  The  late  Mr. 
Grattan,  of  Cork,  used  the  osteoclast  that  goes  by  his  name 
(Fig.  346)  to  crush  and  to  overcorrect  resistant  club-foot.  The 
operation  may  include  besides  the  correction  of  the  deformity  of 
the  foot  itself  fracture  of  the  leg  above  the  malleolus,  to  turn  the 
foot  toward  valgus,  and  a  second  fracture  half-way  up  the  leg, 
to  overcome  the  inward  rotation  or  twist  of  the  tibia.  Mr. 
Grattan's  results  have  been  very  satisfactory.  Other  appliances 
constructed  on  somewhat  similar  principles  may  be  employed. 
Of  these  the  Lorenz  osteoclast^  and  the  Bradford^  lever  apparatus 
are  the  most  effective. 

The  Open  Incision  Combined  with  Forcible  Rectification  of 
Deformity.  Phelps'  Operation.  When  extensive  division  of 
contracted  parts  is  indicated  the  open  incision  is  to  be  preferred 
because  of  the  opportunity  thus  oifered  for  the  recognition  and 
for  intelligent  selection  of  structures  that  require  division  in  the 
final  correction  of  the  deformity. 

Phelps'  operation  is  essentially  simply  the  division  of  resistant 
parts  through  an  incision  on  the  inner  border  of  the  foot,  com- 
bined with  sufficient  force,  manual  or  instrumental,  to  overcorrect 

1  Wiener  Klinik,  November,  December,  1895.  2  Bradford  and  Lovett,  2d  ed.,  p.  414. 


DEFORMITIES  OF  THE  FOOT. 


779 


the  deformity  It  is  the  mo^t  conservative  of  the  more  radical 
procedures,  and  by  it  even  the  most  severe  type  of  deformity  in 
the  adult  can  be  corrected ;  that  is  to  say,  the  deformity  may  be 
overcome  and  a  serviceable  foot  may  be  assured  to  the  patient. 
Perfect  functional  cure  is  not  possible  when  deformity  has  become 
habitual  after  many  years  of  neglect. 

The  steps  of  the  Phelps  operation  are  as  follows  :  After  proper 
surgical  preparation  the  Esmarch  bandage  is  applied.  The  tendo 
Achillis,  and  usually  the  posterior  ligaments  of  the  ankle,  are 


The  deformity  (Fig.  473)  corrected  by  Phelps'  operation  and  by  cuneiform  osteotomy 
of  the  OS  calcis. 


divided  subcutaneously,  and  by  manual  or  instrumental  force 
one  attempts  to  correct  the  plantar  flexion.  An  incision  is  then 
made  on  the  inner  border  of  the  foot,  just  below  and  in  front  of 
the  internal  malleolus,  which  is  extended  directly  downward  over 
the  head  of  the  astragalus  to  include  the  inner  quarter  of  the  sole. 
Through  the  incision  all  resistant  parts  are  divided  in  order,  as 
stated  by  Phelps. 

1 .  Tlie  tibialis  posticus,  and  the  anticus  if  it  offers  resistance. 

2.  The  abchictor  hallucis. 

3.  The  plantar  fascia. 


780 


OB  THOPEDIG  SUBGEB  Y. 


4.  The  flexor  brevis  digitorum. 

5.  The  long  flexor  of  the  toes. 

6.  The  deltoid  ligament  in  all  its  branches. 

During  the  successive  division  of  the  tissues  repeated  attempts 
are  made  to  correct  the  foot,  and  only  those  structures  are  divided 
that  present  themselves  as  tense  and  resistant  tissues  when  the 
foot  is  forcibly  abducted. 

In  the  adult  type  of  club-foot  no  particular  effort  is  made  to 
recognize  the  different  structures,  but  all  the  tissues  on  the  inner 

Fig.  475. 


Resistant  club-foot  in  later  childhood.    (See  Fig.  476.; 


side  of  the  foot,  including  bloodvessels  and  nerves,  the  deep  liga- 
ments, and  occasionally  the  tendon  of  the  peroneus  longus  muscle, 
are  divided.  Even  then  it  is  necessary  to  apply  considerable 
force  to  correct  the  deformity.  In  certain  instances  the  rectifica- 
tion of  deformity  necessitates  osteotomy  of  the  neck  of  the 
astragalus  or  the  removal  of  a  cuneiform  section  from  the  os 
calcis.  The  object  of  the  Phelps  operation  is,  by  division  of 
resistant  tissues  and  by  the  use  of  force,  to  overcorrect  the  de- 
formed foot  at  one  sitting,  and  as  much  force  and  as  extensive 


DEFORMITIES  OF  THE  FOOT.  781 

division  of  tissues  as  are  required  to  accomplish  this  object  should 
be  employed  by  the  operator. 

When  the  foot  can  be  held  in  the  desired  position  without 
resistance,  the  wound  is  covered  with  Lister  protective,  the  foot 
and  leg  are  thickly  covered  with  gauze  and  cotton,  a  plaster 
bandage  is  applied,  and  the  limb  is  elevated.  The  large  gaping 
wound  closes  by  granulation  in  from  one  to  three  months.  The 
first  bandage  is  usually  changed  at  the  end  of  a  month,  and  the 
patient  then  begins  to  bear  weight  on  the  foot. 

By  this  operation  the  foot,  even  in  severe  cases  in  adult  life, 
may  be  made  straight  in  appearance.  It  is  evident,  however, 
that  in  such  cases  the  correction  of  the  deformity  of  the  bones  is 
by  no  means  always  perfect,  for  the  forefoot  may  be  simply 
twisted  outward  and  upward,  while  the  astragalus  and  os  calcis 
may  remain  in  an  approximation  to  their  original  deformity. 
After  thorough  overcorrection  by  the  Phelps  operation  the  danger 
of  recurrence  of  deformity  in  the  adult  and  adolescent  type  of 
club-foot  is  not  great,  and  in  many  instances  support  other  than 
that  of  the  plaster  bandage  for  several  months  after  the  operation 
may  be  unnecessary  ;  but  in  childhood  the  ordinary  precautions 
in  after-treatment  to  prevent  relapse  will  be  necessary. 

Operations  on  the  Bones. 

Osteotomy  of  the  neck  of  the  astragalus,  as  a  supplementary 
part  of  the  operation  of  forcible  correction,  has  been  mentioned. 
In  certain  instances,  particularly  in  the  adolescent  or  adult  type 
of  deformity,  the  displaced  astragalus  may  offer  such  an  obstacle 
to  correction  that  its  removal  is  indicated — an  operation  first  per- 
formed by  Mr.  Lund,  of  Manchester. 

Astragalectomy.  The  astragalus,  which  in  club-foot  is  displaced 
forward,  may  be  removed  easily  by  means  of  an  incision  passing 
over  its  most  prominent  part,  in  a  direction  forward  and  down- 
ward from  the  tip  of  the  external  malleolus,  between  the  tendons 
of  the  peroneus  brevis  and  tertius.  The  soft  parts  are  drawn 
aside,  the  ankle  and  astragalonavicular  joint  are  opened,  and  the 
attachments  to  the  scaphoid,  and,  as  far  as  ]>ossible,  those  at  the 
inner  and  outer  border,  are  divided.  The  foot  is  then  adducted 
80  that  the  head  of  the  bone  may  be  seized  with  forceps  and 
drawn  upward,  the  interosseous  ligament  and  tlic  internal  lateral 
ligament  liaving  \h:va\  divided  witli  curved  scissors,  and  the  bone 
is  removed.      If  after   removal  of  the  astragalus  the  deformity 


782 


ORTHOPEDIC  SURGERY. 


cannot  be  corrected,  the  anterior  part  of  the  os  calcis  or  the 
external  malleolus  should  be  removed  as  well.  A  useful  movable 
foot  may  be  obtained  by  this  operation,  but  it  by  no  means  assures 
the  patient  from  recurrence  of  deformity.  It  is  never  indicated 
as  a  primary  operation,  in  childhood  at  least.  The  varus  should 
be  thoroughly  corrected  as  a  preliminary  procedure  ;  then  the 
resistance  that  the  astragalus  offers  to  dorsal  flexion  can  be 
estimated  (Fig.  476). 


Fig.  476. 


Fig.  477. 


After  forcible  correction  and  astraga- 
lectomy.     (See  Fig.  475.) 


Partially  corrected    club-foot,  showing 
secondary  knock-knee. 


Cuneiform  Osteotomy.  The  removal  of  cuneiform  sections 
of  bone  from  the  outer  border  of  the  foot  is  sometimes  indicated 
when  the  deformity  is  of  long  standing,  but  the  operation  should 
be  secondary  to  other  methods  of  correction.  The  aim  should  be 
to  lengthen  the  contracted  and  shortened  tissues  on  the  inner 
border  of  the  foot  to  the  extent  required  for  reposition,  not  to 
remove  bone  to  accommodate  these  shortened  tissues.  If  this 
has  been  shown  to  be  impossible  by  ordinary  means,  then 
removal  of  bone  may  be  indicated ;  but  it  is  not  often  neces- 
sary in  childhood  or  even  in  adolescence.     If  sufficient  bone  is 


DEFORMITIES  OF  THE  FOOT.  783 

removed  from  the  adult  foot  to  permit  complete  correction  of  the 
deformity,  relapse  is  not  usual;  but  in  childhood,  as  has  been 
stated,  no  operation  will  take  the  place  of  after-treatment. 

The  treatment  by  cuneiform  osteotomy  as  it  is  ordinarily  car- 
ried out  is  sufficiently  simple.  In  severe  cases  the  astragalus  is 
usually  removed,  and  a  wedge-shaped  section  of  bone  is  taken  from 
the  OS  calcis,  cuboid,  and,  if  necessary,  it  may  include  the  scaphoid 
bone  also.  The  external  malleolus  may  be  removed  if  it  inter- 
feres with  reposition.  Preliminary  fasciotomies  and  tenotomies 
are  usually  performed,  but  those  who  favor  this  method  of  treat- 
ment rarely  use  force  in  reposition.  If  the  deformity  is  less 
marked  the  astragalus  is  not  removed,  but  a  part  of  its  body  and 
neck  is  included  in  the  cuneiform  resection.  The  foot  is  retained 
in  proper  position  until  the  wounds  are  closed ;  then  plaster  ban- 
dages are  employed  for  several  months.  Braces  are  seldom  used 
in  the  after-treatment. 

Secondary  Osteotomy.  In  certain  cases  of  relapsed  or  in- 
effectively treated  club-foot,  even  in  childhood,  deformity  of  the 
OS  calcis  either  interferes  with  correction  of  the  foot  or  favors 
relapse.  In  such  instances  the  removal  of  a  (mneiform  section  of 
bone  from  the  anterior  extremity,  as  a  supplementary  part  of 
overcorrection,  may  be  of  service. 

Simple   Mechanical  Rectification  of  Deformity  in  Walking 
Children  and  in  Later  Years. 

It  has  been  stated  that  simple  mechanical  rectification  of  de- 
formity was  possible  even  in  adolescence,  but  that  the  time 
required  for  such  treatment,  usually  extending  over  several  years, 
as  a  rule,  excluded  it  from  consideration. 

The  simplest  mechanical  treatment  is  that  by  which  the  foot  is 
slowly  forced  from  equinovarus  into  equinovalgus  by  a  brace  on 
the  lever  principle,  which  is  at  first  shaped  to  the  deformity,  and 
is  then  gradually  straightened  as  the  resistance  diminishes.  When 
the  midpoint  has  been  passed  between  varus  and  valgus  the 
weight  of  the  body  aids  in  the  correction  of  the  remaining  varus 
and  equinus.  The  modification  of  the  Taylor  brace  used  by  Jud- 
son,  an  advocate  of  pure  mechanics  in  the  treatment  of  club-foot, 
will  serve  to  illustrate  the  type  of  apparatus  which,  with  slight 
change,  may  be  emj^loyed  to  correct  or  to  support  the  Aveakened 
or  deformed  foot. 

The  brace   consists  of  an  upright,  a  flat,  tapering  bar  of  mild 


784 


ORTHOPEDIC  SURGERY. 


steel,  a  foot  plate  of  steel  from  18  to  16  gauge,  and  a  strong  calf 
band.  The  shape  of  the  brace,  the  method  of  its  attachment  to 
the  leg  by  straps  of  webbing,  and  its  effect  in  gradually  changing 
the  attitude  of  the  foot  from  varus  to  valgus  are  shown  in  the 
accompanying  figures. 

The  upright  is  firmly  riveted  to  the  foot  plate  in  the  angle  of 
deformity,  so  that  the  patient  must  walk  upon  his  toes ;  as  the 
equinus  is  decreased  by  the  influence  of  the  weight  of  the  body 
this  angle  is  lessened  (Fig.  480). 


Fig.  478. 


Fig.  479. 


The  Judson  brace.  Fig.  478  shows  the  construction  of  the  brace ;  the  foot  plate,  with  the 
internal  flange  or  "  riser,"  the  upright  riveted  to  it,  and  the  calf  band.  Fig.  479  shows  the 
brace  adjusted  to  fit  the  deformed  foot. 


The  important  points  are  that  the  brace  shall  be  strong 
enough  to  hold  its  place  under  the  strain  of  use  and  that  the 
foot  shall  be  firmly  secured  to  it,  whether  one  or  many  straps  of 
webbing  are  required,  as  may  be  seen  in  the  figures.  The  use  of 
massage  and  manipulation  is,  of  course,  combined  with  the 
mechanical  treatment. 

By  persistent  attention  to  the  details  of  treatment  satisfactory 
results  can  be  obtained  by  this  method  in  the  less  resistant  cases, 
even  in  adolescence. 

Recapitulation  of  the  Principles  of  Treatment  of  Congen- 
ital Talipes  Equinovarus.     The  object  of  treatment  is  to  over- 


DEFORMITIES  OF  THE  FOOT. 


785 


come  and  to  overcorrect  the  deformity  at  as  early  a  period  of  life 
as  is  possible,  and  as  quickly  as  possible.  The  object  of  over- 
correction is  to  overcome  all  the  resistance  of  the  tissues  that  may 
even  in  the  slightest  degree  limit  the  normal  range  of  motion  in 
any  direction.  The  foot  must  be  fixed  in  the  overcorrected  posi- 
tion until  the  recoil  of  the  tissues  toward  deformity  is  no  longer 
present. 

It  must  be  supported  in  the  proper  relation  to  the  leg,  and 
at  a  right  angle  with  it,  until  the  muscular  balance  has  been 


Fig.  480. 


Fig.  481. 


Fig.  482. 


Showing  the  progressive  reduction  of  deformity.  Fig.  480  shows  the  ordinary  attitude  of 
the  neglected  club-foot  in  childhood  with  the  adjustment  of  the  brace,  it  being  bent  to 
accommodate  the  deformity.  Fig.  481  shows  additional  details — an  upright  spur,  useful  in 
holding  the  heel  and  for  the  attachment  of  straps ;  the  spur  of  sheet  brass  that  may  be  bent 
over  the  great  toe  to  hold  it  in  position.  Fig.  482  shows  other  details  in  the  method  of 
attachment,  a  strip  of  adhesive  plaster,  with  two  tails  in  the  place  of  the  band  of  webbing. 
This  aids  in  fixing  the  heel.    (See  Figs.  483  and  484.) 


re-established  by  stimulation  of  the  weaker  and  by  limitation  of 
the  activity  of  the  stronger  muscles,  and  until  transformation  of 
the  internal  structure  has  been  completed. 

If  efficient  mechanical  treatment  is  applied  at  the  proper  time 
— that  is  to  say,  in  earliest  infancy — no  operation  other  than 
division  of  the  tendo  A  chillis  will  be  required. 

If  the  d(;forniity  is  not  corrected  or  is  but  partially  corrected 
when   the  child  begins  to  walk,  some  form  of  operation   is,  as  a 

50 


786 


ORTHOPEDIC  SURGERY. 


rule,  indicated ;  but  division  of  the  resistant  tissues  must  always 
be  combined  with  the  employment  of  sufficient  force  to  accom- 
plish the  desired  result,  viz.,  overcorrection  of  the  deformity. 
Forcible  manual  correction,  applied  in  the  manner  described,  is 
the  most  efficient  means  of  attaining  this  object.  No  instrument 
can  equal  the  hand,  and  the  force  that  can  be  applied  by  the 
hand  is  sufficient  in  all  the  ordinary  cases  in  early  childhood,  and, 
in  combination  with  subcutaneous  division  of  the  more  resistant 
tendons  and  ligaments,  even  in  later  childhood  and  adolescence. 


Fig.  483. 


Fig.  484. 


Showing  the  progressive  reduction  of  deformity,  and  illustrating  the  process  of  changing 
the  shape  of  the  brace  from  time  to  time  until  it  holds  the  foot  in  valgus.    (See  Fig.  480.) 

Forcible  correction  by  the  Thomas  wrench  under  the  same 
conditions  is  an  efficient  treatment,  but  there  is  a  manifest  disad- 
vantage in  submitting  a  patient  to  a  succession  of  operations, 
even  of  so  slight  a  character,  if  immediate  overcorrection  can  be 
attained  by  other  means. 

The  Phelps  operation,  which  combines  thorough  division  of  the 
resistant  parts  with  the  application  of  proper  force  to  overcorrect 
the  foot,  is  the  operation  of  selection  for  the  more  resistant  cases 
in  adolescence,  in  adult  life,  and  in  extremely  resistant  cases  in 
childhood. 


DEFORMITIES  OF  THE  FOOT.  787 

Astragalectomy  and  cuneiform  osteotomy  are  never  indicated 
as  primary  operations,  but  one  or  the  other  may  be  necessary  for 
the  complete  rectification  of  the  deformity  when  other  means  have 
failed. 

Complete  cure  of  deformity,  even  in  the  later  years  of  child- 
hood, is  possible  by  means  of  braces  alone,  but  such  treatment  is 
very  tedious.  It  requires  not  only  the  continuous  supervision  of 
the  skilled  surgeon,  but  the  intelligent  and  persistent  co-operation 
of  the  parents.  The  results  are  in  no  way  superior  to  those 
attained  by  more  rapid  methods,  while  the  disadvantages  of  long- 
continued  use  of  braces  are  sufficiently  obvious.  To  the  popular 
faith  in  braces  as  a  cure-all  of  deformity,  and  to  the  unintelligent 
use  of  braces,  may  be  ascribed  now,  as  in  former  times,  the 
failures  in  treatment  of  this  eminently  curable  deformity.  This 
statement  seems  justified  even  when  balanced  by  the  equally  fal- 
lacious belief,  so  prevalent  among  physicians,  that  a  radical 
operation,  if  it  does  not  absolutely  assure  a  cure,  is,  at  least,  the 
essential  part  of  the  treatment. 

Rectification  of  deformity,  by  whatever  means,  simply  com- 
pletes the  first  stage  of  treatment.  Perfect  cure  can  only  be 
assured  by  attention  to  the  small  details  of  after-treatment,  by 
checking  the  slightest  impulse  toward  deformity,  and  by  guiding 
the  unbalanced  foot  toward  perfect  functional  use. 

Other  Varieties  of  Congenital  Talipes. 

Forms  of  congenital  distortion  of  the  foot  other  than  equino- 
varus  are  not  uncommon ;  but,  as  a  rule,  these  deformities  are  so 
slight  and,  as  compared  to  equinovarus,  so  easily  remedied  that 
they  are  relatively  of  little  importance.  This  distinction  does 
not  apply,  however,  to  acquired  talipes,  which  will  be  considered 
in  the  succeeding  chapter. 

Congenital  Talipes  Varus.  Eighty-five  cases  of  simple  varus 
are  recorded  in  the  table  of  statistics  in  a  total  of  1660  congenital 
deformities  of  the  foot. 

This  deformity  often  appears  to  be  an  incomplete  form  of 
equinovarus,  but  in  some  instances  there  is  simply  a  slight  inward 
twist  of  the  foot  without  supination  (Fig.  425) ;  in  fact,  the  fore- 
foot is  apparently  drawn  inward  by  the  active  movement  of  the 
great  toe,  which,  in  such  cases,  sooms  almost  prehensile.  (See 
Pigeon-toe.)  In  the  more  mark(!d  form  the  foot  is  adducted  and 
supinated,  and  the  tissues  are  very  resistant. 


788  ORTHOPEDIC  SURGERY. 

The  slight  grades  of  deformity  may  be  treated  by  simple 
manipulation,  and  if  deformity  remains  after  the  first  year  the 
shoe  will,  as  a  rule,  correct  it.  The  more  marked  varieties  must 
be  treated  like  the  varus  deformity  of  ordinary  club-foot,  by 
braces  or  by  plaster,  until  the  varus  has  been  transformed  into 
valgus.  The  after-treatment  is  the  same  as  that  for  ordinary 
club-foot. 

Congenital  Talipes  Equinus.  This  is  a  rare  congenital 
deformity,  about  half  as  common,  according  to  the  statistics,  as 
varus  (40  cases  in  1(360).  The  term  equinus  implies  that  dorsal 
flexion  is  limited,  but  that  the  foot  is  not  deviated  to  one  or  the 
other  side  (toward  valgus  or  varus).  In  congenital  equinus  the 
deformity  is,  as  a  rule,  slight,  and  in  many  instances  it  may  be 
overcome  by  gentle  manual  force  applied  frequently.  In  the 
more  resistant  type  mechanical  correction  or  tenotomy,  followed 
by  overcorrection  and  support,  may  be  necessary. 

Congenital  Talipes  Calcaneus.  Congenital  calcaneus  is  com- 
paratively rare  (28  cases  in  1660).  As  a  rule,  the  heel  is 
prominent,  the  foot  is  habitually  dorsiflexed,  and  the  dorsum  can 
be  easily  brought  into  contact  with  the  crest  of  the  tibia  (Fig. 
439).  The  exaggerated  cavus  that  is  usually  present  in  acquired 
calcaneus  is  absent.  Occasionally  the  deformity  is  accompanied 
bv  hyperextension  of  the  knee  ;  and  if,  as  in  many  instances,  there 
is  a  history  of  breech  presentation,  it  may  be  inferred  that  the 
attitude  before  birth  was  one  of  extreme  flexion  of  the  thighs 
upon  the  abdomen,  the  anterior  surfaces  of  the  extended  legs 
being  pressed  closely  to  the  ventral  surface  of  the  body,  the  feet 
being  fixed  in  an  attitude  of  dorsiflexion.  As  a  rule,  the  defor- 
mity is  slight,  and  the  resistance  of  the  tissues  on  the  anterior  aspect 
of  the  leg  can  be  easily  overcome  by  massage  and  manipulation. 
The  foot  should  be  gently  forced  toward  plantar  flexion  several 
times  in  the  day,  and  the  weak  muscles  of  the  calf  should  be 
stimulated  by  massage. 

Cure  may  be  hastened  by  the  use  of  some  simple  form  of 
retention  splint  to  hold  the  foot  in  plantar  flexion  until  the  pos- 
terior group  of  muscles  has  recovered  its  power.  Tenotomy  or 
other  operative  treatment  is  rarely  required. 

In  rare  instances  the  tibia  may  be  bent  slightly  backward, 
thus  increasing  the  deformity.  In  such  cases  the  distortion  of 
the  bone  may  be  overcome  by  manipulation  and  by  apparatus. 

Congenital  Talipes  Valgus,  Congenital  valgus  (Fig.  440) 
is  somewhat  more  common  than  the  preceding  varieties  (123  in 


DEFORMITIES  OF  THE  FOOT. 


789 


1660).  Not  iufrequently  it  is  combined  with  a  slight  degree  of 
calcaneus  or  equinus.  The  resistance  of  the  contracted  tissues 
is  not  great,  and  the  deformity  may  be  overcome,  in  most  cases, 
by  persistent  manipulation.  If  the  muscular  power  is  sufficiently 
unbalanced  to  warrant  it  the  foot  should  be  fixed  in  the  over- 
corrected  position  (varus)  for  a  time. 

Congenital  valgus  is  one  form  of  what  is  known  as  weak 
ankle,  and  it  frequently  passes  unnoticed  until  the  child  begins 
to  walk.  If  at  that  time,  in  spite  of  massage,  the  muscles  appear 
weak  or  if  the  foot  inclines  outward  when  weight  is  borne,  it  is 


Fig.  485. 


Congenital  calcaneovalgus. 


well  to  make  the  sole  of  the  shoe  wedge-shaped,  the  thicker  part 
(one-quarter  of  an  inch)  on  the  inner  side.  In  more  persistent 
cases  a  brace  may  be  necessary,  as  described  in  the  treatment  of 
the  acquired  variety.     (See  Weak  Foot.) 

Talipes  equinovalgus  is  less  common  (28  in  1660).  This 
must  be  treated  as  the  other  varieties,  by  complete  overcorrection 
of  deformity,  manual  or  otherwise,  and  by  subsequent  massage 
and  support  if  necessary. 

Calcaneovalgus  (15  in  1660),  calcaneovarus  (7  in  1660), 
equinocavus  (1  in  1660),  valgocavus  (1  in  1660),  cavus  (5  in 
1660j,  are   extremely   rare,   as    indicated   by   the   statistics.     If 


790 


ORTHOPEDIC  SURGERY. 


treated  early  by  persistent  massage  supplemented  by  retention 
apparatus,  these,  as  well  as  nearly  all  slighter  grades  of  congen- 
ital deformity,  may  be  corrected  and  cured  even,  before  the  child 
begins  to  walk. 

Congenital  Deformities  of  the  Foot  Associated  with 
Defective  Development. 

Talipes  Equinovalgus  Associated  with  Congenital  Absence  of  the 
Fibula.  This  is  a  rare  deformity,  but  the  most  common  of  this 
class.     The  foot  at  birth  is  usually  in  an  attitude  of  well-marked 

Fig.  486. 


Congenital  equinovarus,  with  deformity  of  the  great  toes. 


and  resistant  equinovalgus.  The  leg  is  somewhat  shorter  than 
its  fellow,  and  the  tibia  is  often  bent  sharply  forward,  some- 
times to  an  acute  angle,  at  a  point  somewhat  below  the  centre,  as 
if  it  had  been  broken  in  utero.  At  the  most  prominent  point  the 
skin  may  be  adherent  or  it  may  present  a  dimpled  appearance. 
In  some  instances  the  formation  of  the  foot  is  perfect,  but  more 
often  one  or  more  of  the  outer  toes,  with  the  corresponding 
metatarsal  bones,  are  absent  (Fig.  487). 


DEFORMITIES  OF  THE  FOOT. 


791 


Statistics.  Haudek  collected  from  the  literature  97  cases.  Of 
these  46  were  in  males,  21  were  in  females,  and  in  30  the  sex 
was  not  recorded.  In  67  (69  per  cent.)  there  was  total  absence 
of  the  fibula.  In  30  the 
defect  was  partial ;  of  the 
lower  extremity  of  the  fibula 
in  17,  of  the  upper  extremity 
in  9,  and  of  the  middle  in 
2  cases.  In  27  cases  both 
fibulae  were  absent  or  defec- 
tive ;  in  68  one  only  —  the 
right  in  31,  the  left  in  25, 
and  in  the  others  the  side 
was  not  recorded.  In  61 
cases  toes  were  lacking,  and 
in  these  cases  it  may  be  in- 
ferred that  the  correspond- 
ing metatarsal  bones  were 
absent  also.  The  fourth  and 
fifth  toes  were  absent  in  27 
cases  ;  the  little  toe  alone  was 
missing  in  15.  In  many  in- 
stances, as  is  usual  in  cases 
of  defective  development,  de- 
formity of  other  parts  was 
present ;  for  example,  in  1 7 
instances  the  patella  was  ab- 
sent or  undeveloped,  and  in 
11  the  upper  extremities  were 
defective.' 

Etiology.  The  cause  of 
deformity,  associated  with 
absence  of  bone,  may  be 
either  an  original  defect  in 
the  germ  or  it  may  be  due 
to  interference  with  its  development.  In  some  instances  am- 
niotic adhesions  may  be  one  of  the  predisposing  causes ;  the 
sharp  bend  in  the  tibia,  so  often  present,  may  be  due  to  the 
lessened  resistance  of  the  defective  part. 


Defective  formation  of  the  lower  limb,  illus- 
trating progress  in  shortening. 


1  Gotten  and  Chute.  Boston  Medical  and  Surgical  Journal,  1898,  Nos.  8  and  9  (128  cases). 
Mazzitelli,  Arch.  Ortopedia,  1898,  F.  .5.  Boinet,  Revue  d'OrthopMie,  November,  1899.  Vide 
alsfjErail  Haln  (U.'i cases),  ArchivOrthop.  Mcchaniotherapie  iind  Qnfal  (Jhir.,  Bd.  i.  H.  1, 1903. 


792  ORTHOPEDIC  SURGERY. 

Treatment.  The  indications  for  treatment  are  to  correct  the 
deformity  of  the  foot  in  the  usual  manner.  The  bend  in  the 
tibia  may  be  straightened  by  manipulation  and  splinting,  or  by 
osteotomy  if  necessary.  When  the  patient  begins  to  walk  the 
foot  must  be  supported.  A  light  steel  upright  on  the  outer  side 
of  the  leg,  provided  with  a  T-strap  to  hold  the  leg  against  it,  will 
supply  the  place  of  the  missing  fibula.  The  growth  of  the  tibia 
is  retarded  and  a  final  shortening  of  three  or  more  inches  may 
be  expected,  but  with  care  a  useful  limb  may  be  assured. 

Talipes  Varus  or  Equinovarus  Associated  with  Congenital  Absence 
of  the  Tibia.  Defective  formation  of  the  tibia  is  much  less 
common  than  that  of  the  fibula.  JoachimsthaP  records  31  cases. 
Of  the  25  cases  in  which  the  sex  was  recorded  17  were  males 
and  8  females.  In  23  instances  the  defect  was  of  one  side ;  in 
8  both  tibise  were  defective.  In  most  cases  the  femur  is  some- 
what shortened  and  its  lower  extremity  is  imperfectly  developed. 
In  a  third  of  the  cases  the  patella  was  absent,  and  in  many 
instances  other  malformations  were  present.  In  nearly  all  the 
cases  there  was  flexion  contraction  at  the  knee  and  the  fibula  was 
dislocated  backward.  The  foot  is  practically  always  in  an  attitude 
of  varus.  The  toes  may  be  normal,  but  in  a  number  of  instances 
the  great  toe  was  lacking.  In  possibly  a  third  of  the  cases  a 
portion  of  the  tibia,  usually  the  upper  extremity,  was  present.^ 

The  prognosis  as  regards  a  useful  limb  is  extremely  bad.  The 
growth  of  both  the  thigh  and  the  leg  is  much  retarded,  and  it  is 
almost  impossible  to  balance  the  foot  ujjon  the  fibula  by  any  form 
of  brace. 

The  ordinary  treatment,  after  the  correction  of  the  deformity 
of  the  foot,  has  been  to  resect  the  extremities  of  the  femur 
and  the  fibula  to  induce  anchylosis.  No  final  results  have  been 
reported,  but  it  may  be  assumed  that  an  artificial  limb  would 
provide  a  more  useful  support  than  the  short  and  distorted 
extremity. 

Congenital  Deficiency  and  Hypertrophy.  The  leg  bones  may  be 
perfectly  formed,  but  one  or  more  bones  of  the  foot  itself  may 
be  absent.  In  these  cases,  after  the  reduction  of  the  deformity, 
a  support  to  hold  the  defective  foot  in  its  proper  relation  to  the 
leg  must  be  used. 

The  foot  may  be  divided  into  two  parts,  so  that  it  resembles  a 
lobster  claw.     Supernumerary  toes,  or  deficiency  of  toes,  or  hyper- 

'  Zeits.  f.  Orth.  Chir.,  vol.  iii.  p.  140. 

-  Lanois  and  Kuss  report  40  cases.    Revue  d'Orthop6die,  November,  1901. 


DEFORMITIES  OF  THE  FOOT.  793 

trophy  of  one  or  more  of  the  toes,  with  or  without  corresponding 
overgrowth  of  the  foot  or  leg,  are  not  extremely  uncommon. 

These  deformities  must  be  treated  on  ordinary  surgical 
principles. 

Constricting  Bands. 

Tightly  constricting  bands  of  scar-like  tissue,  which  cause 
deep  indentations  in  the  flesh  of  the  foot  or  leg,  are  sometimes 
seen.  These  are  supposed  to  be  caused  by  amniotic  adhesions. 
"  Spontaneous  amputations  "  of  toes  or  of  the  foot  itself  are  due 
to  the  same  cause  (Fig.  443). 

In  ordinary  cases  the  bands  require  no  treatment,  but  if  they 
interfere  with  the  nutrition  of  the  foot  they  may  be  removed. 

Cong-enital  (Edema  of  the  Feet. 

In  rare  instances,  sometimes  in  combination  with  deformity, 
the  tissues  of  the  feet  appear  to  be  oedematous,  although  the  circu- 
lation seems  to  be  perfect.  The  condition  is  apparently  due  to 
obstruction  of  the  lymphatic  circulation. 

It  should  be  treated  by  massage  and  by  compression. 

Spinal  Bifida  and  Talipes. 

Talipes  coexisting  with  spina  bifida  should  be  treated  as  are 
other  forms  of  club-foot.  If  paralysis  of  the  lower  extremities 
be  present,  as  is  often  the  case,  the  corrected  feet  must  be  sup- 
ported as  in  the  ordinary  forms  of  paralytic  deformity.^ 

1  Ueber   missbildungen    der  Menschilichen   Gliedmassen    und    ihre   entstehungsweise, 
Klausner,  1900. 


CHAPTER    XXIII. 

DEFOEMITIES  OF  THE  FOOT  (Continued). 

Acquired  Talipes. 

In  the  account  of  the  congenital  deformities  of  the  foot  it  was 
stated  that  the  form  known  as  eqiiinovarus  was  by  far  the  most 
common,  and  that  as  compared  with  it  the  other  deformities  were 
of  slight  importance. 

In  the  acquired  varieties  of  talipes  the  equinovarus  deformity 
is  much  less  common,  the  proportion  in  the  congenital  form  being 
77  per  cent,  and  in  the  acquired  32.5  per  cent,  of  the  total 
number.  Acquired  equinus  comes  next  in  frequency,  26  per 
cent,  as  compared  with  2.4  per  cent,  of  the  congenital  deformity ; 
and  every  variety  and  combination  of  distortion  finds  its  repre- 
sentative in  acquired  talipes,  as  may  be  seen  in  the  tables.  (See 
page  742.) 

Etiology.  The  cause  of  acquired  talipes  is  almost  always 
paralysis.  In  the  table  of  statistics  it  Avill  be  seen  that  in  82.8 
per  cent,  the  paralysis  was  of  spinal  origin  (anterior  poliomyelitis). 
In  11.3  per  cent,  it  was  cerebral,  the  talipes  being  a  part  of  the 
deformity  of  hemiplegia  or  paraplegia.  In  a  few  cases  the  de- 
formity was  caused  by  local  disease  or  by  local  paralysis,  and 
the  remainder,  or  5.4  per  cent.,  were  of  traumatic  origin. 

The  distinction  between  the  two  varieties  of  talipes,  congenital 
and  acquired,  has  already  been  emphasized.  In  the  congenital 
form  the  deformity  is  the  essential  disability,  for  when  deformity 
has  been  rectified  the  most  difficult  part  of  the  treatment  has 
been  accomplished  and  perfect  cure  may  be  expected.  In  the 
acquired  form  the  straightening  of  the  foot  is  but  a  preliminary 
part  of  the  treatment,  for  cure  is  not  to  be  expected  except  in 
that  small  proportion  of  cases  in  which  the  primary  disease  of 
the  spinal  cord  has  caused  no  permanent  injury  to  its  structure, 
or  in  which  the  deformity  was  the  result  of  some  slight  or  pass- 
ing disability  or  of  disease  or  injury.  Congenital  talipes  cannot 
be  anticipated  or  prevented.  Acquired  talipes  is  an  effect  of  par- 
alysis only  when  protective  treatment  has  been  neglected.     It  is  a 


DEFORMITIES  OF  THE  FOOT.  795 

result,  therefore,  that  may  be  foreseen,  and  thus,  by  proper  treat- 
ment, prevented. 

Development  of  Deformity.  The  characteristics  of  anterior 
poliomyelitis  are  described  elsewhere.  (Chapter  XVII.)  In  its 
effect  upon  the  foot  the  usual  sequence  is  somewhat  as  follows : 
At  the  onset  the  paralysis  is  usually  widespread,  affecting  an 
entire  limb,  for  example  ;  then  follows  a  period  of  partial  recovery, 
after  which  the  amount  of  damage  that  the  spinal  cord  has 
sustained  may  be  estimated.  It  is  during  the  period  of  partial 
recovery,  the  six  months  or  more  following  the  attack,  that 
deformity  develops.  If,  for  example,  the  anterior  group  of  leg 
muscles  is  paralyzed,  the  foot  habitually  hangs  downward,  an 
attitude  induced  by  the  force  of  gravity  and  by  the  contraction  of 
the  unaffected  posterior  group.  If  it  is  allowed  to  persist  the 
tissues  accommodate  themselves  to  the  new  position  ;  the  active 
muscles  which  are  never  extended  to  their  normal  limit  become 
structurally  shortened,  while  the  weakened  or  paralyzed  muscles 
are  correspondingly  overstretched.  Even  within  a  few  weeks 
after  the  onset  of  the  paralysis  the  evidences  of  progressive  de- 
formity are  plain.  The  contracted  tissues  resist  passive  motion 
in  the  directions  opposed  to  the  habitual  attitude,  and  the  child 
shows  evidence  of  pain  if  force  is  used  to  increase  the  limited 
range  of  motion.  As  has  been  stated  already,  acquired  talipes 
is  an  unnecessary  deformity.  It  may  be  prevented  by  support- 
ing the  paralyzed  part  in  a  right-angled  relation  to  the  limb, 
and  by  systematic  passive  movements  throughout  the  entire  range 
of  normal  motions. 

Anterior  poliomyelitis  is  most  common  during  the  second  year 
of  life,  or  when  the  child  has  already  begun  to  walk.  When  the 
first  or  more  general  effect  of  the  disease  has  passed  away  the 
child  again  uses  the  disabled  limb  as  best  it  may ;  thus  the  dis- 
tortion of  the  foot  is  increased  and  confirmed  by  the  weight  of 
the  body  and  by  functional  use  in  the  abnormal  attitude. 

The  final  deformity,  in  a  particular  case,  can  be  predicted  from 
a  knowledge  of  the  function  of  the  muscles  which  have  been  dis- 
abled. For  example,  paralysis  of  the  tibialis  anticus,  the  most 
powerful  dorsiflexor  and  adductor  of  the  anterior  group,  must 
result  in  equinovalgus.  If  the  peroueus  brevis  and  tertius  are 
affected  varus  will  follow.  Paralysis  of  the  calf  muscles  will 
cause  calcaneus.  Paresis  or  paralysis  of  the  entire  anterior  group 
will  cause  equinus.  If  all  the  muscles  are  paralyzed,  what  is 
called  a  dangle-foot  is  the  result ;  the  cold,  atrophied  member 


796  ORTHOPEDIC  SUBGEBY. 

dangles  from  the  attenuated  limb,  with  but  little  tendency  to 
deformity  unless  it  is  capable  of  use,  when  it  is  usually  forced 
into  an  attitude  of  equinovarus  or  valgus. 

A  slight  degree  of  paralysis  may  cause  so  little  immediate 
disability  that  it  may  be  entirely  overlooked,  and  yet  it  may  be 
sufficient  to  induce  disability  or  deformity  even,  in  later  years. 
This  fact  has  been  mentioned  in  the  etiology  of  the  contracted  foot. 

Differential  Diagnosis  between  Congenital  and  Acquired 
Deformity.  The  history  itself  usually  indicates  the  etiology,  for 
deformity  of  the  foot  at  birth  is  never  overlooked  by  the  mother. 
Acquired  talipes  is  of  slow  development,  and  it  is  practically 
always  preceded  by  disease,  weakness,  or  injury. 

In  paralytic  talipes  (anterior  poliomyelitis)  there  is  evidence  of 
paralysis  in  loss  of  function  of  certain  muscles,  as  shown  by 
electrical  stimulation  or  by  pricking  the  foot  with  a  pin ;  later, 
in  the  atrophy  of  the  muscles  and  often  in  the  evident  change  in 
the  nutrition  and  diminished  growth  of  the  limb. 

Only  in  neglected  and  extreme  cases  of  talipes  in  the  adolescent 
or  adult  could  there  be  difficulty  in  distinguishing  between  the 
acquired  and  the  congenital  deformity.  In  rare  instances,  it  is 
true,  paralysis  may  be  present  at  birth,  due  to  intra-uterine  dis- 
ease or  to  defect  in  the  nervous  apparatus.  In  such  cases  the 
cause  of  the  paralysis  is  usually  apparent  (spina  bifida,  or  spastic 
paralysis  associated  with  defective  cerebral  development),  and 
the  treatment  does  not  differ  from  that  of  the  acquired  form. 

Acquired  Talipes  Equinus 

In  well-marked  equinus  the  foot  is  plantar  flexed  to  its  full 
limit,  and  it  is  fixed  in  this  attitude  by  the  shortened  structures 
on  the  posterior  aspect  of  the  leg,  of  which  the  tendo  Achillis  is 
the  most  important.  The  patient  walks  upon  the  heads  of  the 
metatarsal  bones,  the  toes  being  dorsiflexed  to  accommodate  the 
deformity.  The  arch  of  the  foot  is  increased  in  depth  and  the 
tissues  of  the  sole,  particularly  the  plantar  fascia,  are  contracted. 
The  entire  foot  is  broadened  and  shortened,  the  breadth  being 
especially  increased  at  the  anterior  metatarsal  region  (Fig.  438). 
Corresponding  to  the  exaggerated  depth  of  the  arch,  the  dorsum 
projects,  the  cuneiform  bones  are  prominent,  and  the  head  and 
body  of  the  displaced  astragalus  may  be  felt  beneath  the  skin  on 
the  anterior  surface  of  the  foot.  In  the  slighter  degrees  of  the 
deformity,  when  the  patient  still  walks  upon  the  sole  of  the  foot, 


DEFORMITIES  OF  THE  FOOT. 


7d7 


the  toes  are  usually  dorsiflexed — an  attitude  due  apparently  to  the 
overaction  of  the  extensor  lougus  digitorum  and  proprius  hallucis, 
as  aids  in  dorsiflexion  (Fig.  488). 

In  rare  instances,  and  only  in  those  cases  in  which  all  the 
anterior  muscles  are  paralyzed,  the  toes  may  be  plantar  flexed 
so  that  the  patient  walks  upon  their  dorsal  surface. 

The  cavus  or  increased  depth  of  the  arch  is  due  primarily  to 
the  falling  downward  of  the  forefoot  at  the  mediotarsal  joint,  and 
in  many  instances  this  dropping  of  the  forefoot  is  in  great  degree 
responsible  for  the  equinus ;  in  fact,  the  os  calcis  is  rarely  plantar 
flexed  to  the  degree  commonly  found  in  the  ordinary  congenital 
equinus. 


Fig.  488. 


Acquired  talipes  equinus,  showing  the  limit  of  dorsal  flexion. 


The  cases  of  slight  equinus  combined  with  cavus  have  been 
described  already  under  the  title  of  the  contracted  foot  (page  699). 
The  exaggerated  arch  is  a  secondary  and  a  late  result  of  the 
paralysis  and  of  the  equinus.  In  the  slight  degrees  of  deformity, 
particularly  in  the  early  stage  of  the  paralysis,  it  may  be  absent. 

Etiology.  Equinus  in  the  slighter  degrees  is  the  most  common 
of  the  forms  of  talipes  acquired  in  later  life.  Anterior  poliomy- 
elitis, although  by  far  the  most  common  cause,  is  by  no  means 
as  important  in  the  etiology  of  this  as  of  other  varieties  of  defor- 
mity. The  nerve  supply  of  the  anterior  muscles  of  the  foot 
seems  to  be  particularly  susceptible,  and  toe-drop,  from  neuritis 
of  various  types,  is  not  uncommon. 


798  ORTHOPEDIC  S URGEB  Y. 

Equinus  may  be  a  result  of  disease  of  cerebral  origin,  or  even, 
in  rare  instances,  of  pseudohypertrophic  muscular  paralysis  or 
locomotor  ataxia.  It  is  sometimes  induced  by  habitual  posture, 
as  after  long  confinement  in  bed  for  the  treatment  of  fracture 
or  during  the  treatment  of  hip  disease  by  apparatus.  Or  the  con- 
traction may  be  an  effect  of  voluntary  posture,  as  when  the 
patient  habitually  walks  upon  the  toes  because  of  a  short  leg.  It 
is  a  very  common  sequel  of  neglected  disease  at  the  ankle-joint, 
and  it  may  be  a  result  of  direct  injury. 

The  changes  in  the  internal  structure  of  the  foot  are  similar  to 
those  that  follow  other  forms  of  deformity ;  the  tissues  on  the 
long  side  are  lengthened  and  attenuated,  while  those  on  the  short 
side  become  contracted.  The  bones  themselves  are  but  little 
changed  in  gross  appearance,  but  the  articulating  surfaces  are  in 
abnormal  relation  to  one  another  ;  for  example,  only  the  posterior 
part  of  the  astragalus  may  be  contained  within  the  malleoli  in 
relation  to  the  tibia,  while  only  the  lower  part  of  its  anterior  sur- 
face articulates  with  the  navicular.  In  all  cases  of  equinus  there 
is  a  strong  tendency  toward  varus  or  valgus.  This  is  especially 
noticeable  in  those  of  paralytic  origin. 

Symptoms.  The  effects  of  the  deformity  vary.  If  the  limb 
is  actually  shorter  than  its  fellow,  so  that  the  lengthening  caused 
by  the  extension  of  the  foot  is  no  more  than  a  sufficient  compen- 
sation, and  if  the  foot  is  firmly  fixed  in  the  deformed  position, 
surprisingly  little  discomfort  or  disability  may  be  experienced 
other  than  from  corns  or  calluses  beneath  the  metatarsal  bones. 

If  the  limb  is  not  shorter  the  additional  length  caused  by  the 
equinus  must  be  compensated  by  a  tilting  of  the  pelvis  and  lateral 
deviation  of  the  spine.  This  often  gives  rise  to  symptoms  of 
discomfort  in  the  lumbar  region.  The  gait  in  this  class  of  cases 
is  always  awkward,  giving  the  impression  as  of  stepping  over  an 
obstacle. 

If  the  foot  is  not  fixed  in  the  attitude  of  equinus — that  is,  if  it 
hangs  downward  when  it  is  lifted — the  gait  is  very  awkward, 
because  of  the  insecurity  and  because  of  the  exaggerated  flexion 
at  the  knee  necessary  in  order  that  the  pendent  foot  may  not  drag 
upon  the  ground. 

If  the  equinus  is  extreme  the  limb  is  usually  flexed  at  the 
knee  when  in  use ;  if  the  equinus  is  slight,  so  that  the  foot  may 
be  used  in  the  plantigrade  position,  the  strain  resulting  from  the 
limitation  of  dorsal  flexion  is  felt  at  the  knee  ;  and  in  childhood 
at  least  there  is  often  a  well-marked  tendency  to  overextension 


DEFORMITIES  OF  THE  FOOT.  799 

or  recurvation,  caused  by  the  effort  to  place  the  heel  upon  the 
ground. 

In  the  slight  degrees  of  equinus  discomfort  about  the  calf  is 
experienced ;  the  limitation  of  dorsal  flexion  causes  a  rather 
shortened  stride  and  awkward  gait,  while  an  unguarded  step  that 
throws  a  sudden  strain  upon  the  rigid  heel  cord  is  felt  as  a  shock 
and  strain  through  the  leg  and  body.  Very  often  the  patient 
complains  of  pain  about  the  metatarsal  bones  (anterior  metatar- 
salgia),  and  if  the  equinus  is  accompanied  by  a  slight  degree  of 
valgus,  as  is  not  uncommon,  symptoms  of  the  weak  foot  may  be 
present. 

The  prognosis  as  to  permanent  cure  depends,  of  course,  upon 
the  cause  of  the  deformity.  When  it  is  simply  the  result  of 
posture  or  of  the  ordinary  form  of  neuritis  and  the  like,  perma- 
nent cure  may  be  expected.  In  many  of  the  cases  that  have 
followed  anterior  poliomyelitis  recovery,  complete  or  partial,  of 
the  original  injury  to  the  spinal  centres,  has  occurred.  Although 
voluntary  control  of  the  muscles  has  been  regained,  it  cannot  be 
exercised  because  the  foot  is  held  in  the  distorted  position  by  the 
contracted  tissues.  In  such  instances  practical  cure  may  be  pre- 
dicted if,  after  the  overcorrection  of  deformity,  sufficient  time  is 
allowed  for  the  overstretched  and  atrophied  muscles  to  regain 
their  proper  length  and  volume. 

Treatment.  In  the  cases  of  fixed  equinus  combined  with  a 
shortened  limb  in  which  the  patient  suffers  no  discomfort  it  is 
well  to  allow  the  position  to  remain,  a  shoe  being  so  built  that 
the  heel  may  support  a  part  of  the  weight.  In  the  more  extreme 
cases  in  which  the  limb  is  short  and  the  foot  is  atrophied  an 
extension  shoe,  attached  after  the  manner  of  an  artificial  leg,  may 
be  worn  with  comfort  and  with  but  little  evidence  of  deformity. 

In  the  ordinary  cases,  whether  permanent  cure  is  expected  or 
not,  the  rule  holds  good  that  the  heel  should  bear  the  weight  of 
the  body,  and  that  the  range  of  dorsal  flexion  should  not  be 
limited  when  the  calf  muscle  retains  its  power.  If  the  nervous 
apparatus  has  received  permanent  injury  the  foot  must  be  sup- 
ported after  the  deformity  has  been  corrected  ;  but  even  in  this 
class  the  gait  may  be  improved  and  the  discomfort  may  be 
relieved  Ijy  removing  the  restrictions  to  normal  motion. 

The  slight  degrees  of  equinus  in  young  subjects  may  be  over- 
come by  simple  manipulation  or  by  retention  in  a  splint  or  in  a 
{)laster  l^andage.  If  the  foot  is  fixed  l)y  a  plaster  bandage  at  a 
right  angk;  to  the  leg  it  will  be  found  after  a  few  weeks  that  the 


800 


ORTHOPEDIC  SUBGEBY. 


range  of  dorsal  flexion  has  been  increased  by  the  rest  and  by 
functional  use.  In  older  subjects  manual  stretching  of  the  con- 
tracted tissues  is  of  service  ;  for  example,  the  patient  being  seated 
extends  the  limb ;  the  surgeon  stands  in  front  of  him,  one  hand 
holds  the  leg  firmly  at  the  ankle,  and  the  other  grasps  the  foot, 
which  is  then  dorsiflexed  over  and  over  again  with  as  much 
force  as  is  consistent  with  the  comfort  of  the  patient. 

The  Shaffer  extension  shoe  is  also  a  useful  appliance  for  treat- 
ment of  the  milder  degrees  of  equinus,  and  especially  so  because 


Fig.  489. 


Fig.  490. 


A  brace  with  a  "  limited  "  joint,  allowing 
slight  motion  at  the  ankle. 


A  brace  to  prevent  foot-drop.    One  upright 
is  often  sufficient. 


it  may  be  employed  to  reduce  the  accompanying  cavus  at  the 
same  time. 

The  weight  of  the  body  as  a  means  of  overcoming  equinus 
when  the  foot  is  held  in  its  proper  relation  to  the  leg  by  a  brace 
or  by  a  plaster  bandage  has  been  mentioned,  but  this  tedious 
method  has  but  little  to  recommend  it  in  the  cases  of  more 
resistant  type.  The  elastic  tension  of  straps  and  bands  attached 
to  a  brace  or  to  the  foot  itself  by  means  of  adhesive  plaster  is 
of  some  service  in  slight  cases ;  but  by  far  the  most  effective 


DEFORMITIES  OF  THE  FOOT.  801 

method  is  the  immediate  reduction  of  the  deformity  by  simple 
forcible  manipulation  under  anaesthesia,  or  by  tenotomy  combined 
with  forcible  manipulation  or  wrenching. 

Immediate  Correction  of  Deformity.  Attention  has  been  called 
to  the  cavus  as  an  important  element  in  equinus,  and  whenever 
one  attempts  to  correct  the  equinus  deformity  by  force  the  exag- 
gerated arch  should  be  reduced  to  its  normal  depth,  otherwise 
the  foot  will  appear  stunted  and  deformed. 

One  of  the  most  eifective  procedures  is  forcible  reduction  by 
means  of  the  Thomas  wrench  (Fig.  472).  The  resistant  bands 
of  the  plantar  fascia  are  first  divided  subcutaneously,  the  wrench 
is  then  fixed  to  the  foot,  and  with  sudden  force  exerted  against 
the  resistant  tendo  Achillis  the  foot  may  be  straightened,  the 
deep  ligaments  being  ruptured  or  stretched  to  the  proper  degree. 
The  resistance  to  normal  dorsal  flexion  is  then  overcome  by 
manual  force,  or,  if  this  is  ineffective,  by  subcutaneous  division 
of  the  tendo  Achillis,  and  the  foot  is  fixed  by  a  plaster-of-Paris 
bandage  in  an  attitude  of  dorsiflexion. 

As  the  patient  is  encouraged  to  walk  upon  the  foot  as  soon  as 
possible,  the  weight  of  the  body  forcing  the  relaxed  tissues  against 
the  plaster  sole,  reinforced,  if  necessary,  by  a  wooden  foot  plate, 
completes  the  flattening  of  the  arch.  In  many  of  these  cases  the 
knee  has  been  overextended  by  use  in  the  deformed  attitude,  so 
that  the  habitual  flexion  necessary  to  bring  the  dorsiflexed  foot 
upon  the  ground  during  the  two  months  allowed  for  the  complete 
union  of  the  divided  tendon  is  of  benefit,  as  it  serves  to  correct 
this  secondary  weakness  and  deformity. 

The  Tonic  Effect  of  Immediate  Correction.  The 
importance  of  the  tonic  effect  of  immediate  relief  of  the  strain  of 
the  deformed  position  upon  the  weak  anterior  group  of  muscles, 
together  with  the  complete  relaxation  of  the  overstretched  tissues, 
during  the  long  rest  in  the  overcorrected  position  is  not  generally 
appreciated.  Whenever  the  weakened  muscles  after  paralysis 
show  by  tests,  electrical  or  otherwise,  that  they  have  recovered 
their  power  in  part,  overcorrection  of  the  deformity  should  be 
the  treatment  of  selection.  The  application  of  electricity  or  other 
form  of  stimulation  to  muscles  that  are  unable  to  exercise  their 
function  because  of  contraction  of  the  opposing  tissues  is  absolutely 
useless  ;  nor  is  any  other  form  of  artificial  stimulation  equal  to 
that  of  the  functional  use,  which  is  made  possi])le  by  the  removal 
of  the  deformity  and  by  the  employment  of  proper  support. 

Equinus,  more  often  than  any  other  deformity,  is  the  result  of 

51 


802 


ORTHOPEDIC  SURGERY. 


slight  or  temporary  disability  of  the  anterior  group  of  muscles, 
and  not  infrequently  perfect  cure  seems  to  have  been  attained 
when  the  plaster  bandage  is  finally  removed,  usually  at  the  end  of 
two  months  or  more ;  but  even  in  such  cases  the  application  of 
a  simple  support  to  hold  the  foot  at  a  right  angle  with  the  leg  for 
several  months  is  of  advantage.  The  after-treatment  by  massage, 
muscle-beating,  electricity,  and  the  like,  combined  with  method- 
ical passive  movements   to  the  limit  of  dorsal  flexion  to  guard 


Fig.  491. 


An  eflFective  aud  inconspicuous  support  for  paralytic  toe-drop.  An  uprignt  of  light  tem- 
pered steel,  carefully  adjusted  to  the  inner  side  of  the  leg  and  ankle,  provided  with  a  light 
calf  band.  This  is  strengthened  by  a  posterior  support  attached  to  the  upright.  The  lower 
end  of  the  brace  is  arranged  as  a  caliper  and  is  fitted  to  the  metal  disk,  of  which  two  views 
are  shown.  A  depression  is  cut  in  the  heel  of  the  shoe  for  the  disk,  as  is  shown  in  the  dia- 
gram. Two  strong  elastic  tapes  are  sewed  to  the  leather  of  the  shoe.  These  are  attached 
to  the  studs  on  the  front  of  the  calf  band,  and  thus  the  toe-drop  is  prevented.    (See  Fig.  492.) 

against  recontraction  of  the  calf  muscle,  should  be  continued  for 
a  long  time  or  until  the  muscular  balance  has  been  regained. 

Support  is,  of  course,  necessary,  in  cases  of  hopeless  paralysis, 
to  hold  the  foot  at  a  right  angle  with  the  leg.  The  common 
form  is  a  simple  steel  sole  plate  of  sufficient  size  to  support  the 
sole,  and  the  toes,  also,  if  their  muscles  are  paralyzed,  attached  to 
a  light  upright,  provided  with  a  calf  band.  The  upright  is 
usually  applied  on  the  inner  side  of  the  leg,  where  it  is  least 


DEFORMITIES  OF  THE  FOOT. 


803 


Fig.  492. 


noticeable.  At  the  ankle  there  is  a  "  stop  joint/'  which  allows 
dorsiflexion  but  prevents  the  toe-drop.  This,  when  properly 
fitted,  can  be  placed  inside  the  ordinary  shoe,  as  the  paralyzed 
foot  is  usually  somewhat  smaller  than  its  fellow  (Fig.  490).  If 
the  toes  do  not  need  support, 
the  upright  can  be  attached 
to  the  outside  of  the  shoe  and 
the  foot  plate  may  be  dis- 
pensed with  ;  or,  the  upright 
may  be  concealed  by  intro- 
ducing it  inside  the  shoe  to 
a  joint  sunk  in  the  heel,  the 
toe-drop  being  prevented  by 
straps  passing  from  the  front 
of  the  upper  leather  of  the 
shoe  to  the  calf  band  (Fig. 
491). 

Arthrodesis.  In  this  class 
of  cases  in  which  the  ante- 
rior muscles  are  paralyzed 
the  operation  of  arthrodesis 
for  the  purpose  of  fixing  the 
foot  at  a  right  angle  with 
the  leg  is  of  value.  In  most 
cases  anchylosis  must  be  se- 
cured at  the  mediotarsal  as 
well    as    at   the  ankle-joint. 

TT     1        J.1       -r<  11         1  The  same  appliance  (Fig.  491)  provided  with  a 

Under  the  ii,smarch  bandage    foot  plate  of  metal  or  of  wood,  as  shown  in  the 

the  two  joints  are  opened  by   ^\^^'^?^-  tms  modification  is  useful  if  the  par- 

J  r  J     alysis  IS  complete  or  ifthe  foot  IS  much  atrophied. 

an  incision  in  the  centre  of 

the  foot,  beginning  about  one  inch  above  the  ankle-joint  and  ex- 
tending downward  for  about  three  inches.  The  cartilaginous  sur- 
faces of  the  astragalus  and  leg  bones  may  be  removed  easily  with 
a  narrow-bladed  knife  or  thin,  sharp  chisel,  while  the  foot  is 
held  in  plantar  flexion.  At  the  mediotarsal  joint  a  thin,  wedge- 
shaped  section,  base  upward,  including  the  astragalonavicular 
and  calcaneocuboid  joints,  may  be  removed  also  in  order  to  pre- 
vent the  subsequent  sinking  of  the  forefoot. 

If  there  is  restriction  of  dorsal  flexion  the  foot  should  be  forced 
up  to  a  right  angle  with  the  leg  against  the  resistance  of  the  tendo 
Achillis,  thus  determining  the  apposition  of  the  denuded  surfaces. 
In  other  instances  silk  sutures  may  be  passed  through  the  perios- 


804  ORTHOPEDIC  S UB GEE  Y. 

teum  of  the  opposing  bones.  The  wound  is  then  closed  with 
catgut  and  a  plaster-of- Paris  bandage  is  applied  to  hold  the  foot 
at  a  right  angle  with  the  leg.  Operations  of  this  character  on 
the  bones  are  sometimes  followed  by  swelling.  On  this  account 
the  bandage  should  be  applied  tightly  over  a  thick  layer  of  elastic 
cotton  and  the  foot  should  be  elevated.  As  soon  as  the  discom- 
fort has  subsided  the  patient  should  use  the  foot  in  walking. 
No  support  is  equal  in  efficiency  to  the  plaster  bandage,  and  this 
should  be  worn  for  several  months,  when  it  may  be  replaced  by 
a  light  supporting  brace  of  the  Judson  type  (Fig.  494). 

Equinus  due  to  posture  or  to  disease,  not  involving  paralysis, 
may  be  cured  by  simple  correction  of  the  deformity.  That  due 
to  fracture,  when  the  deformity  is  caused  by  displacement  of  the 
bones,  may  be  treated  by  direct  operation  or  by  the  removal  of  a 
cuneiform  section  from  the  anterior  surface  of  the  tibia  above  the 
ankle.     (See  Tendon  Transplantation.) 

Acquired  Talipes   Calcaneus. 

Acquired  talipes  calcaneus  is  much  less  common  than  equinus, 
and  it  is  practically  always  of  paralytic  origin  (anterior  polio- 
myelitis), although  cases  of  calcaneus  following  injury  or  disease 
or  distortion  of  the  limb  are  occasionally  seen. 

There  are  several  varieties  or  grades  of  the  deformity.  In  the 
early  stage,  and  especially  if  all  the  muscles  of  the  posterior  group 
have  been  paralyzed,  the  foot  assumes  an  attitude  of  slight  dorsi- 
flexion,  and  the  range  of  plantar  flexion  is  gradually  lessened  by 
secondary  contractions.  This  variety  resembles  closely  the  con- 
genital form  (simple  calcaneus)  (Fig.  439).  In  the  ordinary  and 
typical  form  of  calcaneus,  when  fully  developed,  the  patient 
walks,  as  the  name  implies,  on  an  elongated  heel.  The  arch  of 
the  foot  is  much  increased  in  depth,  and  the  forefoot  is  atrophied 
and  useless  (calcaneocavus)  (Fig.  495). 

Development  of  Deformity.  The  development  of  the  deformity 
is  somewhat  as  follows  :  When  the  tension  of  the  calf  muscle  is 
removed  the  os  calcis  gradually  assumes  an  attitude  of  extreme 
dorsiflexion.  It  stands  on  end,  so  that  its  posterior  surface 
becomes  inferior.  The  posterior  projection  of  the  heel  is  lost, 
and  it  lies  in  the  plane  of  the  atrophied  calf.  The  change  in  the 
position  of  the  os  calcis  increases  the  distance  from  the  malleoli 
to  the  ground  ;  thus  calcaneus,  though  in  less  degree  than  equinus, 
makes  the  limb  longer.     The  turning  of  the  heel  on  end  increases 


DEFORMITIES  OF  THE  FOOT.  805 

the  depth  of  the  longitudinal  arch  and  at  the  same  time  shortens 
the  foot,  thus  cavus,  in  more  marked  degree  than  with  equinus, 
accompanies  calcaneus.  The  cavus  is  a  later  complication  of  nearly- 
all  cases  of  paralytic  calcaneus.  In  many  instances  there  is  no 
permanent  dorsiflexion  or  elevation  of  the  forefoot,  although  in 
all  cases  the  range  of  plantar  flexion  is  limited.  In  this  class  the 
power  in  the  remaining  muscles  of  the  posterior  group  is  probably 
sufficient  to  counterbalance  the  action  of  the  dorsiflexors.  Cavus 
is  thus  a  direct  effect  of  the  displacement  of  the  os  calcis.  If 
the  entire  posterior  group  of  muscles  is  paralyzed,  while  the 
anterior  muscles  are  unaffected,  the  foot  will  be  somewhat  dorsi- 
flexed  and  the  cavus  will  be  less  marked.  If  the  calf  muscle  only 
(gastrocnemius  and  soleus)  is  paralyzed,  the  remaining  muscles 
of  the  posterior  group  will  counterbalance  the  dorsiflexors  and  at 
the  same  time  increase  the  cavus.  In  some  instances  the  calf 
muscle  alone  is  affected ;  in  others  one  or  more  of  the  smaller 
muscles  may  be  paralyzed  also,  in  which  case  the  foot  is  usually 
turned  toward  varus  or  valgus.  The  changes  primarily  caused 
by  the  paralysis  and  by  unopposed  muscular  action  become  fixed 
by  habitual  use  and  by  secondary  adaptation  of  the  tissues.  The 
heel  only  is  used  in  walking,  and  the  area  of  callus  which  marks 
the  weight-bearing  surface  becomes  much  enlarged,  while  the 
forefoot  and  toes,  which  have  but  little  functional  use,  become 
atrophied — a  mere  appendage  to  the  enlarged  heel  (Fig.  496). 

Symptoms.  The  gait  is  awkward  and  inelastic ;  the  patient, 
who  is,  as  it  were,  "  hamstrung,"  stamps  along  upon  the  insecure 
support  of  the  heel  in  a  manner  which  is  easily  recognizable  by 
one  familiar  with  the  deformity.  The  changes  in  the  internal 
structure  of  the  foot,  the  inevitable  adaptations  to  the  deformity, 
do  not  call  for  special  description.  The  disused  bones  atrophy 
together  with  the  other  tissues,  and  new  articulating  surfaces 
form  to  accommodate  the  necessities  of  functional  use. 

Treatment.  The  essence  of  successful  treatment  is  prevention. 
When  the  diagnosis  of  paralysis  of  the  calf  muscle  is  made  one 
may  predict,  unless  recovery  takes  place,  a  deformity  such  as  has 
been  described.  This  deformity  may  be  prevented  by  proper 
support,  by  massage,  and  methodical  stretching  of  the  tissues  that 
have  a  tendency  to  contract.  The  form  of  brace  used  for  walking 
and  support  should  be  provided  with  a  sole  plate,  upright,  and 
calf  band,  as  already  described  in  the  treatment  of  paralytic 
equinus.  Jf  motion  is  allowed  at  the  ankle  it  should  be  in  plantar 
flexion  only,  the  stop  being  the  reverse  of  that  used  in  equinus ; 


806 


ORTHOPEDIC  SUBOEBY. 


or,  as  this  form  of  check  entails  much  strain  upon  the  brace,  the 
joint  may  be  omitted,  as  in  that  form  used  by  Judson  (Figs.  493 
and  494).  Thus  the  strain,  removed  from  the  weakened  tissues, 
is  borne  by  the  anterior  surface  of  the  leg.  Other  forms  of 
braces  are  sometimes  employed,  provided  with  elastic  bands  to 
supply  the  place  of  the  calf  muscle ;  but,  as  a  rule,  the  improve- 
ment in  gait  hardly  compensates  for  the  trouble  in  adjustment  or 
the  conspicuousness  of  the  appliance. 

The  most  important  part  of  the  actual  deformity  of  calcaneus 
is  the  cavus,  in  great  degree  due  to  the  changed  position  of  the 
OS  calcis ;  and  in  confirmed  cases  it  is  practically  impossible  to 


Fig.  493. 


Fig.  494. 


Judson's  brace  for  calcaiieous  deformity. 


reduce  this  except  in  part,  because  the  loss  of  resistance  of  the 
tendo  Achillis;  takes  away  the  point  of  fixation  against  which 
effective  force  can  be  exerted.  If  the  deformity  is  not  marked 
the  foot  may  be  drawn  as  far  as  possible  toward  equinus  and  fixed 
in  a  plaster  bandage,  the  sole  part  being  strengthened  by  the  inser- 
tion of  a  thin  board.  Upon  this  the  patient  may  walk,  the  heel 
being  built  up  with  cork  wedges  to  make  the  sole  level.  When 
the  contraction  of  the  anterior  tissues  has  been  overcome  the 
brace  is  applied  and  the  usual  treatment  of  manipulation  and 
massage  is  continued. 

The  method  of  prolonged  fixation  in  the  attitude  of  equinus  by 
means  of  the  plaster  bandage  is  often  efficacious  in  childhood. 


DEFORMITIES  OF  THE  FOOT. 


807 


when  the  paralysis  is  not  complete,  and  cures  of  apparently  hope- 
less cases  by  this  means  have  been  reported/ 

Operative  Treatment.  In  more  extreme  cases  immediate  reduc- 
tion o£  the  deformity  under  anaesthesia  may  be  attempted.  The 
contracted  tissues,  more  particularly  the  plantar  fascia,  may  be 
divided  subcutaneously  or  by  open  incision ;  then  by  forcible 
manipulation  or  wrenching  the  sole  may  be  somewhat  lengthened 
and  the  heel  pushed  upward  and  backward  to  permit  of  slight 
plantar  flexion.     In  this  attitude  the  foot  should   be  fixed  by 


Fig.  495. 


Paralytic  calcaneus,  showing  secondary  changes  in  contour. 


means  of  a  plaster  bandage.  In  the  reduction  of  the  deformity 
one  must  not  merely  force  the  forefoot  downward,'as  this  would 
simply  increase  the  cavus,  but  whatever  correction  is  accomplished 
should  be  by  means  of  elevation  of  the  os  calcis  and  elongation 
of  the  tissues  of  the  sole  of  the  foot.  In  cases  of  extreme  de- 
formity the  contracted  tissues  in  the  anterior  aspect  of  the  ankle 
must  be  divided  also. 

In  some  instances  the  improved  position  of  the  os  calcis  may 

1  Gibney.    TranHactlons  of  the  American  Orthopedic  Association,  1900,  vol.  xiii.    ■ 


808  ORTHOPEDIC  SUROEBY. 

be  confirmed  by  shortening  the  tendo  Achillis,  as  first  performed 
by  Willett,  of  London.^ 

Willett's  Operation  for  Calcaneus.  A  Y-shaped  incision  about 
two  inches  in  length  is  made  through  the  tissues  down  to  the 
tendon.  At  the  lower  or  vertical  part  of  the  incision,  which  is 
continued  down  to  the  tuberosity  of  the  os  calcis,  the  tendon  is 
dissected  free  from  the  surrounding  parts.  It  is  then  divided  in 
an  oblique  direction  from  within  outward  and  downward,  and  the 

Fig.  496. 


Talipes  calcaneus  due  to  paralysis  of  the  calf  muscle  (gastrocnemius  and  soleus), 
illustrating  the  typical  deformity  of  moderate  degree. 

heel  having  been  pushed  upward  as  far  as  possible  the  divided  ends 
are  overlapped  and  sutured ;  the  flap  of  skin  is  drawn  downward 
at  the  same  time,  so  that  the  Y-incision  is  converted  into  the 
shape  of  a  V.  According  to  Mr.  Willett's  original  directions, 
deep  sutures  are  passed  through  the  skin  flaps  and  through  the 
tendon  on  either  side,  so  that  all  the  tissues  are  united.  The 
foot  is  then  fixed  in  a  plaster  bandage  in  an  attitude  of  equinus. 
As  soon  as  practicable  the  patient  begins  to  use  the  foot,  wearing 
a  high  heel  to  compensate  for  the  elevation  of  the  sole. 

1  St.  Bartholomew's  Hospital  Reports,  1880,  vol.  xvi.  p.  309. 


DEFORMITIES  OF  THE  FOOT. 


809 


The  operation  is  of  value  in  those  cases  in  which  some  power 
remains  in  the  calf  muscle,  which  is  thus  made  serviceable. 


Fig.  497. 


Talipes  calcaneovalgus.    In  this  form  the  adductors  of  the  foot  (tibialis  anticus  and 
posticus)  as  well  as  the  calf  muscle  are  paralyzed. 

In  cases  of  complete  paralysis  the  position  of  the  foot  may  be 
temporarily  improved,  but  unless  proper  support  is  used  afterward 


Fig.  498. 


Fig.  499. 


Compare  with  Fig.  49G. 


Compare  with  Fig.  497. 


the  tissues  will  stretch  under  the  strain  of  use ;  thus  the  treat- 
ment should  always  be  supplemented  by  a  brace  of  the  character 
already  described  (Fig.  494). 


810  ORTHOPEDIC  SURGERY. 

Astragalectomy,  Tendon  Transplantation,  and  Backward  Displace- 
ment of  the  Foot  (the  Author's  Operation),^  lu  cases  of  confirmed 
calcaneus  or  calcaneus  combined  with  lateral  deformity,  varus  or 
valgus,  astragalectomy  may  be  indicated.  This  operation  permits 
the  malleoli  to  be  brought  into  direct  contact  with  the  os  calcis, 
thus  increasing  the  security  of  the  foot  and  improving  its  appear- 
ance. 

A  long,  curved,  external  incision  is  made,  passing  from  just 
anterior  to  the  tendo  Achillis  below  the  outer  malleolus  to  the 
front  of  the  joint.  The  peronei  tendons  are  divided  or  drawn  to 
one  side.  The  joint  is  then  opened  and  the  foot  is  displaced  in- 
ward. 

This  forces  the  astragalus  out  from  between  the  malleoli  and 
it  is  easily  removed  when   its  attachments  to   the   neighboring 

Fig.  500. 


Figs.  498,  499,  and  500  illustrate  the  effect  of  treatment  by  removal  of  the  astragalus  and 
backward  displacement  of  the  foot  in  cases  of  paralytic  talipes  calcaneovalgus. 

bones  have  been  divided.  The  articulating  surfaces  of  the  leg 
bones  and  of  the  os  calcis  and  navicular  are  denuded  of  car- 
tilage ;  and,  finally,  the  peronei  tendons,  if  the  muscles  are  active, 
are  attached  to  the  os  calcis,  preferably  by  passing  them  through 
a  hole  bored  just  beneath  the  insertion  of  the  tendo  Achillis,  for 
the  purpose  of  lessening  the  tendency  to  deformity  and  increas- 
ing the  subsequent  stability  of  the  foot.  The  entire  foot  is  then 
displaced  backward  so   that  the   denuded  malleoli  overlap  the 

1  American  Journal  of  the  Medical  Sciences,  November,  1901. 


DEFORMITIES  OF  THE  FOOT.  811 

anterior  extremity  of  the  os  calcis.  The  object  of  this  procedure 
is  to  throw  the  weight  of  the  body  toward  the  centre  of  the 
tarsus  in  order  to  lessen  the  leverage  that  tends  to  force  the 
foot  toward  dorsal  flexion.  The  wound  is  then  closed  without 
drainage,  and  the  foot  is  fixed  in  plaster  of  Paris  in  moderate 
equinus. 

As  soon  as  possible  the  patient  uses  the  foot  in  standing  and 
walking.  Ultimately  apparatus  may  be  dispensed  with,  but  the 
Judson  brace  or  the  appliance  shown  in  Fig.  501  may  be  used 
for  a  year  or  more  with  advantage.  This  operation  has  been 
performed  in  many  instances  by  the  author,  for  whom  it  is  now 

Fig.  501. 


An  effective  brace  for  talipes  calcaneus,  consisting  of  two  light  lateral  steel  bars  joined 
above  by  a  padded  band  of  steel,  which  crosses  the  upper  third  of  the  tibia,  and  below  by  a 
narrow  sole  plate.  A  leather  heel  support  also  adds  somewhat  to  the  efficiency  of  the  appa- 
ratus. In  most  instances  the  heel  should  be  somewhat  elevated  by  a  cork  wedge  placed 
within  the  shoe. 

the  treatment  of  choice  in  this  type  of  deformity.  It  may  be 
stated  that  absolute  anchylosis  does  not  follow  the  denudation  of 
the  bones,  but  this  seems  to  be  of  service  in  lessening  the 
direct  strain  upon  the  articulation.  The  tendon  transplantation 
is  rather  for  the  purpose  of  removing  an  agent  toward  deformity 
if  valgus  is  present  and  to  lessen  the  tendency  toward  deformity 
than  to  replace  the  lost  function  of  the  calf  muscle  (Fig.  499). 
By  this  operation  the  usefulness  of  the  foot  is  greatly  increased 
and  its  appearance  very  much  improved. 


812  OB THOPEDIC  SURGEB  Y. 

Acquired  Calcaneovalgus  and  Calcaneovarus. 

In  many  cases,  the  foot  deformed  as  a  result  of  paralysis  of 
the  calf  muscle  is  in  addition  turned  in  a  lateral  direction,  so 
that  the  weight  of  the  body  falls  to  the  inner  or  outer  side  of  its 
centre  (Fig.  497). 

Calcaneovalgus,  in  which  the  foot  is  turned  outward  and 
upward,  so  that  the  patient  walks  on  the  inner  side  of  the  heel  or 
even  on  the  inner  ankle,  is  not  uncommon.  It  is  usually  a  result 
of  more  extensive  paralysis  than  simple  calcaneus.  For  example, 
all  the  muscles  about  the  foot  may  be  disabled  except  the  peronei, 
or  in  cases  of  a  milder  type  the  tibialis  anticus  may  be  the  only 
muscle  of  the  front  of  the  foot  that  is  paralyzed. 

Treatment.  When  the  foot  inclines  toward  calcaneovalgus  it 
is  difficult  to  hold  it  in  proper  position.  The  usual  method  is  to 
apply  the  brace,  used  for  ordinary  calcaneus,  with  the  upright  on 
the  outer  side  of  the  foot ;  the  ankle  and  arch  are  then  held 
against  it  by  means  of  a  leather  strap.  Another  form  of  brace  is 
provided  with  an  upright  on  either  side  of  the  leg,  the  outer 
being  slightly  longer  than  the  inner,  so  that  the  sole  plate  is  tilted 
inward  or,  as  it  were,  supinated ;  thus  the  weight  is  guided 
toward  and  balanced  on  the  outer  side  of  the  foot.  In  many 
instances  of  this  character  other  muscles  of  the  limb  are  paralyzed, 
the  deformity  of  the  foot  being  but  a  part  of  more  general  dis- 
tortion. In  such  cases  the  foot  brace  must  be  combined  with 
apparatus  for  the  support  of  the  leg  (Fig.  359). 

Calcaneovarus  is  a  much  less  serious  affection,  since  the  foot 
may  be  more  easily  supported.  A  brace,  such  as  is  used  in  the 
treatment  of  ordinary  varus,  without  motion  at  the  ankle  or  pro- 
vided with  a  reverse  stop,  is  ordinarily  employed.  Operative 
treatment  is  indicated  for  confirmed  deformity  of  the  valgus  or 
varus  type  after  the  method  last  described. 


Acquired  Talipes  Equinovarus. 

Talipes  equinovarus  is,  in  the  acquired  as  in  the  congenital 
form,  the  most  common  of  the  deformities  of  the  foot  (Fig. 
505). 

The  tendency  of  simple  equinus  is  usually  toward  varus,  because 
in  plantar  flexion  the  foot  is  slightly  adducted  and  because  the 
outer  side  of  the  foot  is  shorter  than  the  inner  side,  so  that  in 


DEFORMITIES  OF  THE  FOOT.  813 

walking  with  the  foot  extended  the  tendency  of  the  foot  is  to 
turn  somewhat  inward.  Equinovarus  is  usually  preceded  by 
equinus,  and  the  etiology  of  the  one  will  serve  for  the  other 
(page  796). 

In  certain  cases  the  varus  is  more  marked  than  the  equinus, 
as,  for  example,  when  the  abductors  of  the  foot  are  paralyzed 
while  the  adductors  retain  their  power ;  or  in  cases  of  direct 
injury,  as  in  fracture  at  the  ankle ;  or  when  the  growth  of  the 
tibia  has  been  arrested,  as  the  result  of  injury  or  disease. 

A  detailed  account  of  the  appearance  and  effect  of  the  deformity 
is  unnecessary.  In  the  early  stage  of  the  paralysis  it  may  be 
reduced  easily ;  the  foot  must  then  be  supported  by  a  brace,  of 
which  the  Taylor  club-foot  apparatus  is  the  type  (Fig.  463). 
During  the  night  the  overcorrected  attitude  may  be  assured  by  a 
strap  running  from  the  upright  to  the  sole  plate. 

If  the  deformity  is  fixed  it  should  be  reduced  and  overcorrected 
by  forcible  manipulation  under  anaesthesia.  Division  of  resistant 
parts  is  less  often  necessary  than  in  the  congenital  form,  but  it 
may  be  required  in  neglected  cases.  The  overcorrected  position 
should  be  retained  until  time  has  been  allowed  for  the  recontrac- 
tion  of  the  lengthened  tissues  ;  for,  as  has  been  mentioned  in  the 
treatment  of  equinus,  overcorrection  and  rest  is  by  far  the  most 
effective  treatment  that  can  be  applied  to  a  weak  or  paralyzed 
part.     A  support  is  then  used  of  the  character  indicated. 

Astragalectomy  and  cuneiform  osteotomy  are  rarely  indicated, 
but  the  latter  operation  is  sometimes  of  service  in  checking  the 
tendency  toward  recurrence  of  deformity,  which  is  more  persistent 
after  overcorrection  in  the  paralytic  than  in  the  congenital  talipes. 

Transplantation  of  half  of  the  tendon  of  the  tibialis  anticus 
tendon  to  the  periosteum  or  bone  of  the  outer  border  of  the  foot, 
combined  with  arthrodesis  of  the  astragalus  scaphoid  articulation 
in  an  attitude  of  slight  abduction,  is  of  service  as  a  curative 
procedure.     (See  Tendon  Transplantation.) 

Acquired  talipes  equinovalgus  is  much  less  frequent  than  the 
preceding  deformity.  Simple  equinovalgus  is  usually  the  result 
of  primary  paralysis  of  the  tibialis  anticus,  the  most  powerful  of 
the  dorsal  flexors ;  thus  the  foot  is  drawn  somewhat  outward 
when  dorsiflexed,  while  the  metatarsal  bone  of  the  great  toe, 
having  lost  the  proper  support  of  the  paralyzed  muscle,  falls  down- 
ward and  is  drawn  outward  by  the  peroneus  longus.  In  this 
type  one's  attention  is  often  attracted  by  the  peculiar  appearance 
of  the  great  toe,  which  is  deformed  somewhat  like  a  hammer-toe 


814  OB  THOPEDIC  S  UR  GER  Y. 

by  the  overaction  of  the  extensor  longus  hallucis  in  its  attempt 
to  take  the  place  of  the  tibialis  anticus.  The  equinus  is  usually 
slight  and  is  secondary  to  the  valgus.  Treatment  may  be  begun 
by  placing  the  foot  in  a  plaster  bandage  in  an  attitude  of  varus 
and  allowing  the  patient  to  walk  upon  it  until  the  tendency 
toward  deformity  has  been  overcome.  A  support  with  the 
catch,  as  for  toe-drop,  is  applied  to  the  shoe,  and  the  tendency 
toward  valgus  is  checked  by  raising  the  inner  border  of  the  sole 
or  by  the  use  of  a  sole  plate,  as  in  the  treatment  of  the  simple 
weak  foot  (Fig.  413).  In  this  class  of  cases  tendon  transplanta- 
tion, particularly  the  implantation  of  the  tendon  of  the  extensor 
longus  hallucis  in  the  region  of  the  navicular.  Combined  with 
arthrodesis  of  the  astragalonavicular  articulation  in  the  attitude 
of  adduction  is  particularly  effective. 

Acquired  simple  talipes  valgus  from  combined  paralysis  of 
the  tibialis  anticus  and  posticus  is  rare.  Talipes  valgus,  as  when 
the  foot  is  dislocated  outward,  in  cases  of  complete  paralysis  of 
all  its  muscles,  may  be  considered  as  a  variety  of  dangle-foot. 

Traumatic  valgus  and  equinovalgus  caused  by  fracture  at 
the  ankle  (Pott's  fracture)  may  be  treated  by  osteotomy  of  the 
tibia  above  the  ankle.  By  this  means  the  proper  relation  of  the 
leg  to  the  foot  may  be  restored  in  many  instances.  Equinovalgus 
of  slight  degree  is  not  uncommon  after  tuberculosis  or  rheumatoid 
disease  at  the  ankle  or  at  the  astragalonavicular  joints.  This  is 
practically  one  variety  of  weak  foot. 

Talipes  valgus,  sometimes  called  spurious  valgus,  the  simple 
weak  or  flat-foot,  has  been  described  elsewhere.     (Chapter  XX.) 

Talipes  caused  by  cerebral  disease,  whether  of  the  paraplegic 
or  the  hemiplegic  type,  is  in  early  childhood  almost  always  of 
the  form  of  equinovarus.  In  adolescence  the  deformity  may  be 
equinovalgus  or  even  calcaneovalgus  if  there  is  extreme  flexion  at 
the  knee.  The  hemiplegic  form  of  talipes  is  much  more  rigid 
and  unyielding  than  the  paraplegic  type.  The  treatment  of 
spastic  paralysis,  of  which  the  deformity  is  a  part,  is  discussed 
elsewhere.  (Chapter  XVIII.)  The  deformity  must  be  corrected 
by  the  ordinary  methods.  In  many  instances  when  the  contrac- 
tions are  not  marked  mechanical  treatment  is  unnecessary. 
;  :2Hysterical  equinovarus  or  other  form  of  deformity  is  not  espe- 
cially rare.  The  diagnosis  may  be  made  from  the  other  symptoms 
of  hysteria,  from  the  history  of  the  onset  and  duration  of  the 
distortion,  and  from  the  appearance  of  the  deformity,  which  is 
evidently  merely  an  assumed  posture.     (See  page  621.) 


DEFORMITIES  OF  THE  FOOT. 


815 


Tendon  Transplantation  for  the  Relief  of  Paralytic  Talipes. 

When  one  or  more  of  the  muscles  are  paralyzed  the  unbalanced 
action  of  those  that  remain  tends  to  distort  the  foot.  The  object 
of  the  brace  in  such  cases  is  to  hold  the  foot  so  that  the  muscular 
traction,  however  applied,  can  move  it  only  in  the  proper  direc- 
tions. The  object  of  tendon  or  muscle  transplantation  is  to  utilize 
the  muscular  power  that  remains  to  the  best  advantage.  Thus  a 
muscle  which  only  serves  to  distort  the  foot  may  be  transplanted 
to  a  point  where  it  may  restrain  deformity  and  improve  functional 
ability. 

Tendon  transplantation  was  first  performed  by  Xicoladoni  in 
1882^  for  the  relief  of  paralytic  calcaneus.  The  tendons  of  the 
peroneus  longus  and  brevis  were  divided  behind  the  external 
malleolus,  and  the  proximal  ends  united  to  the  distal  extremity 
of  the  divided  tendo  Achillis. 

The  first  operation  on  the  front  of  the  foot  was  performed 
by  Parish,^  of  New  York,  for  the  relief  of  paralytic  valgus,  by 
sewing  the  tendon  of  the  extensor  proprius  hallucis  to  that  of  the 
paralyzed  tibialis  anticus,  without  division  of  either  tendon.  In 
more  recent  years  the  field  of  the  operation  has  been  extended  by 
Drobnik,^  of  Posen ;  Goldthwait,*  of  Boston,  and  many  others, 
to  include  almost  every  possible  combination  of  tendons  and 
muscles.^ 

The  functions  of  the  muscles  and  their  relative  order  of  impor- 
tance in  the  execution  of  each  movement  are  indicated  in  the 
following  table,  modified  somewhat  from  that  of  Codivilla  : 


Dorsal 

Plantar 

Adduc- 

Abduc- 

Prona- 

Supina- 

flexion. 

flexion. 

tion. 

tion. 

tion. 

tion. 

Tibialis  anticus 

1 

1 

Extensor  proprius  hallucis. 
' '        longus  digitorum^     . 

3 

6 

2 

3 

3 

Peroneus  brevis .... 

6 

2 

2 

"         longus 

3 

1 

1 

Gastrocnemius  and  soleus 

1 

2 

2 

Tibialis  posticus 

4 

1 

3 

Flexor  longus  hallucis 

2 

3 

4 

"           "      digitorum  .... 

5 

4 

5 

Time  for  Operation,     The  operation  should  not  be  undertaken 
until  the  degree   of  final  and  irremediable  paralysis   has   been 

1  Archiv  f.  klin.  Chir.,  1882,  iii.,  xxvii.,  S.  660. 

=  New  York  Medical  Journal,  October  8,  1892.  '  Cent.   f.  Chir.,  July,  1894,  N.  7. 

■*  Transactions  of  the  American  Orthopedic  Association,  1896,  vol.  viii. 
'■>   For  a  complete  bibliography  up  to  1902,  see  Vulpius,  Die  Sehnentiberpflanzuug,  etc. 
Leipzig,  1902. 
«  Including  peroneus  tertius. 


Fig.  502. 


Fig.  503. 


-i°f  wi 


c/J  m 


\\1 


GASTRQLCNCMIUS 


If     4 


The  muscles  and  tendons  on  the  front  of  the       The  muscles  and  tendons  on  the  back  of  the 
leg.    (Testut,  from  Gerrish's  Anatomy.)  leg.    (Testut,  from  Gerrish's  Anatomy.) 


DEFORMITIES  OF  THE  FOOT. 


817 


Fig.  504. 


determined.  This  stationary  stage  may  be  reached  in  a  com- 
paratively short  time,  but  in  the  ordinary  cases  in  which,  for 
want  of  protection,  the  part  has  become  distorted,  it  is  practically 
impossible  to  estimate  the  latent  muscular  power  until  the  defor- 
mity has  been  corrected,  and  until  the  enfeebled  muscles  have 
been  stimulated  by  functional  use.  In  general,  a  period  of  two 
years  at  least  should  intervene  between 
the  onset  of  the  paralysis  and  the 
operation. 

The  first  essential  for  success  by  this 
means  is  a  clear  understanding  of  the 
mechanism  of  the  disabled  part  and  of 
the  relative  importance  of  its  functions. 
As  regards  the  foot,  for  example, 
plantar  flexion  is  far  more  important 
than  dorsal  flexion,  because  the  ina- 
bility to  plantar  flex  implies  the  loss 
of  the  principal  lifting  and  propelling 
power  of  the  body.  Dorsal  flexion  is 
more  important  than  adduction  or  ab- 
duction, because  the  drop-foot,  so 
called,  interferes  seriously  with  loco- 
motion. Adduction  is  more  important 
than  abduction,  because  the  loss  of 
power  to  turn  the  foot  inward  induces 
the  attitude  of  valgus,  which  is  more 
disabling  and  more  difficult  to  remedy 
than  the  opposite  deformity.  To  the 
importance  of  these  movements  the 
power  of  the  muscles  corresponds.^ 

Selection  of  Muscles.  In  selecting 
muscles  for  transplantation  one  at- 
tempts usually  to  reduce  the  distorting 
power  as  well  as  to  replace  lost  func- 
tion. For  example,  if  the  tibialis  an- 
ticus  were  paralyzed  one  would  natur-  '^^''^T  i^^^^^^s'^V'^l^    ^?'*"^' 

^  ^      •>  j->«uLtx  from  Gernsh's  ^wato??!2/.) 

ally  replace  It  by  its  adjunct,  the  ad- 
joining tendon  of  the  extensor  hallucis,  and  as  the  power  of  rais- 
ing the  toe  is  not  essential  it  should  be  separated  and  transferred 
entire  to   its  new  position.     This  might  complete  the  operation, 
or  the  principal  abductor  on  the  dorsal  surface  of  the  foot  might 

1  See  Tables  on  pages  669  and  GOO. 
62 


818 


ORTHOPEDIC  SURGERY. 


be  divided  and  the  proximal  end  attached  to  the  periosteum  or 
bone  near  the  centre  of  the  foot  to  further  assure  the  success  of 
the  operation. 

If,  on  the  other  hand,  the  dorsal  abductors  were  reduced  in 
strength  so  that  the  foot  turned  inward  in  dorsitlexion,  the 
tibialis  anticus  tendon  should  be  split,  from  its  insertion  to  the 
muscular  substance,  and  the  outer  half  carried  under  the  other 
tendons  and  fastened  securely  at  or  near  the  insertion  of  the 
peroneus  tertius  as  well  as  to  that  tendon  ;  thus,  the  power  of 
supination  would  be  weakened  and  that  of  pronation  increased. 


Fig.  505. 


Paralytic  equinovarus  before  operation.    (See  Fig.  506.) 

If  the  calf  muscle  is  paralyzed  and  if  the  foot  is  inclined 
toward  valgus  because  of  weakness  of  the  adductor  group,  the 
two  peronei  tendon  may  be  attached  at  the  insertion  of  the  tendo 
Achillis,  not,  of  course,  with  the  aim  of  replacing  its  lost  func- 
tion by  two  such  feeble  muscles,  but  because  they  might  aid  in 
preventing  deformity  and  become  of  some  functional  service,  even 
if  slight. 

Paralysis  of  the  tibialis  posticus  muscle  may  be  treated  by 
dividing  the  peroneus  brevis  at  or  near  its  insertion,  passing  it 


DEFORMITIES  OF  THE  FOOT. 


819 


beneath  the  tenclo  Achillis  and  attaching  it  to  the  tendon  of  the 
former.  It  may  be  mentioned,  also,  that  portions  of  the  tendo 
Achillis  have  been  used  to  strengthen  either  the  posterior 
adductors  and  abductors.  As  has  been  stated,  one  must  plan  the 
operation  according  to  the  function  that  is  lost  and  the  power 
that  remains.  As  a  rule,  the  most  successful  operations  are 
those  in  which  a  muscle  of  similar  function  to  that  of  the 
paralyzed  one  is  transplanted.  It  is  apparent,  also,  that  it  will 
be  of  little  use  to  transpose  a  muscle  unless  its  origin  is  such 
that  it  can   work  to  advantage  at  its  new  point  of  attachment. 

Fig.  506. 


Paralytic  equinovarus  cured  by  operation,  showing  power  of  dorsal  flexion  (one-half  oi 
the  tendon  of  the  tibialis  anticus  attached  to  the  periosteum  of  the  outer  border  of  the  foot). 
Operation  July  19, 1898.  The  direct  union  of  tendons  to  periosteum  at  the  most  advantageous 
point  has  been  urged  recently  by  Lange  ( [/e6er  Pej-iostafe  Sdmenverplavzung  bei  Llihgmwig, 
Milnch.  vied.  Woch.,  1900,  No.  15). 


For  example,  an  anterior  adductor  may  be  changed  to  an 
abductor,  and  a  posterior  adductor  or  abductor  can  be  similarly 
transferred,  but  a  posterior  abductor  is  unlikely  to  be  efficient  as 
a  dorsal  flexor ;  nor  can  one  muscle  act  as  an  extensor  and  as  a 
flexor  at  the  same  time,  as  would  appear  to  be  the  belief  of  those 
who  attach  a  portion  of  the  tendo  Achillis  to  the  tibialis  anticus 
tendon  with  the  aim  of  restoring  the  power  of  dorsal  flexion. 
The  variety  of  combinations  of  this  character  that  have  been 
advocated  is  very  largo,  but  it  is  hardly  necessary  to  describe 
them.      As  has  been  mentioned,  one  may  always  sacrifice  a  less 


820 


OB  THOPEDIC  S  UB  GEB  ¥. 


important  to  a  more  important  function,  and  as  a  weak  muscle 
can  hardly  carry  out  its  original  function  and  a  more  important 
one  as  well  it  is  advisable  in  most  instances  to  relieve  it  com- 
pletely of  the  first  in  making  the  transfer. 

The  Operation.  The  technique  of  the  operation  is  simple.  All 
restriction  to  normal  motion  must  be  overcome  by  manual  force 
and,  if  necessary,  by  tenotomy  as  a  preliminary  measure.  The 
operation  should  be  performed  under  an  Esmarch  bandage. 
The  incision  should  be  long  enough,  as  a  rule,   to   expose  the 

Fn;.  507. 


^ 

r 

^^^^^v 

\ 

J 

Talipes  equinovalgus  after  treatment  by  tendon  transplantation.  The  tendon  of  the 
peroneus  tertius  was  attached  to  the  overlapped  and  shortened  tendon  of  the  tibialis  anticus. 
All  the  tendons  on  the  front  of  the  foot  were  then  united,  so  that  all  might  serve  as  dorsal 
flexors. 

muscular  substance  of  the  muscles  and  the  point  at  which  the 
transplanted  tendon  is  to  be  attached.  By  exposing  the  parts 
one  is  able  to  verify  the  previous  diagnosis.  A  completely  par- 
alyzed muscle  is  atrophied  and  of  a  dull,  reddish-yellow  color, 
and  its  tendon  is  of  a  yellowish-white  tinge.  A  partially  paralyzed 
muscle  is  atrophied,  its  tendon  is  small,  but  it  retains  the  silvery 
glisten  of  the  normal  structure.  The  tendon  sheaths  having 
been  opened,  the  tendon  is  divided  or  split  near  its  insertion,  and 
the  part  to  be  transplanted  is  then  placed  in  apposition  to  the 
tendon  of  the  paralyzed  muscle,  whose  surface  has  been  freshened 


DEFORMITIES  OF  THE  FOOT.  821 

with  the  knife.  The  two  are  then  attached  to  one  another  by 
several  sutures  of  fine  silk,  and  the  graft  is  covered  by  uniting 
the  tendon  sheath  or  fatty  tissue  over  it  with  fine  catgut.  The 
skin  incision  is  closed  with  a  continuous  catgut  suture.  It  should 
be  stated  that  the  graft  is  applied  under  a  certain  tension,  all  the 
slack  being  drawn  in,  as  it  were,  so  that  the  foot  is  held  if 
possible  in  the  normal  attitude.  This  is  further  assured  in  most 
instances  by  shortening  the  tendon  of  the  paralyzed  muscle.  A 
plaster  bandage  is  then  applied  in  the  overcorrected  position,  and 
in  this  attitude  the  foot  should  be  used  for  many  months. 

Modifications  of  the  Operation.  Since  its  introduction  the  oper- 
ation of  tendon  transplantation  has  been  modified  in  several  par- 
ticulars. It  has  been  demonstrated  by  experience  that  there  is 
a  strong  tendency  toward  relapse  to  the  original  condition,  either 
because  of  weakness  of  the  transposed  muscles  or  because  of 
displacement  of  the  new  attachments.  This  indicates  the  neces- 
sity of  long-continued  fixation  in  the  overcorrected  attitude  and 
of  subsequent  support  by  braces  until  one  is  certain  of  the  final 
outcome. 

It  has  been  urged  by  Lange  that  the  tendon  of  the  living 
muscle  should  not  be  attached  to  that  of  the  paralyzed  one,  but 
should  be  fixed  directly  to  the  periosteum  at  the  point  of  greatest 
mechanical  efficiency.  If  the  tendon  is  not  long  enough  for  this 
purpose  it  should  be  lengthened  by  means  of  a  silk  cord  incor- 
porated in  its  substance,  about  which  it  is  assumed  new  tendinous 
material  will  form  during  its  absorption.  Wolff  has  suggested 
implanting  the  end  of  the  tendon  beneath  the  cortex  of  the  bone, 
and  I  have  gone  still  further  in  the  interest  of  security  by  boring 
a  hole  completely  through  the  bone  to  which  the  attachment  is  to 
be  made,  passing  the  tendon  through  it  and  sewing  it  to  itself 
and  to  the  periosteum  on  the  other  side.  Thus,  in  utilizing  the 
extensor  longus  hallucis  to  replace  the  tibialis  anticus  the  hole  is 
made  in  the  navicular.  The  tendon,  having  been  divided  about 
one  inch  from  its  insertion,  is  passed  through  and  drawn  tight 
enough  to  hold  the  inner  border  of  the  foot  at  a  right  angle  to 
the  leg.  The  tendon  of  the  paralyzed  tibialis  anticus  is  then  cut, 
overlapped,  and  sutured  to  aid  in  relieving  the  strain.  If  the 
tibialis  anticus  muscle,  on  the  other  hand,  is  to  be  used  as  an 
abductor  it  is  split  in  the  manner  described,  and  as  it  is  not  long 
enough  for  bone  implantation  a  cord  of  silk  is  quilted  into  it  and 
passed  through  the  cuboid,  while  the  tendon  itself  is  attached  to 
that  of  the  peroneus  fortius  and  to  the  periosteum  in  the  usual 


822  ORTHOPEDIC  SURGERY. 

manner.  Silk  may  be  depended  upon  to  hold  for  about  a  year, 
although  it  is  not  completely  absorbed  for  several  years.  For 
uniting  adjacent  tendons  I  prefer  the  continuous  suture  over  a  wide 
extent  of  surface. 

Tendon  Transplantation  in  Combination  with  Other  Procedures. 
As  the  object  of  operative  treatment  is  to  prevent  deformity  and 
to  increase  the  stability  of  the  foot,  tendon  transplantation  may 
be  of  greater  service  when  combined  with  other  operations.  One 
of  these  has  been  mentioned  in  the  treatment  of  talipes  cal- 
caneus. (See  page  808.)  For  valgus  deformity  arthrodesis  of 
the  astragalonavicular  articalation  in  the  attitude  of  adduction, 
and  for  varus  in  the  position  of  abduction,  are  useful  adjuncts. 
The  operation  is  very  simple.  The  joint  is  opened  by  a  lateral 
or  superior  incision  and  the  cartilage  is  removed  with  a  knife  or 
sharp  chisel.  As  a  rule,  when  the  foot  is  forced  into  the  over- 
corrected  position  the  cut  surfaces  are  fixed  in  apposition. 

The  foot  should  be  retained  for  several  months  in  the  over- 
corrected  position  in  the  plaster  bandage,  on  which  the  patient 
walks  about  until  the  foot  has  become  adapted  to  the  new  posi- 
tiou.  In  many  instances  further  support  is  unnecessary,  but  a 
brace  should  be  used  if  there  is  a  tendency  toward  deformity. 

The  prognosis  depends  upon  the  degree  of  permanent  paralysis 
and  its  distribution.  It  is,  of  course,  evident  that  tendon  trans- 
plantation is  essentially  a  palliative  rather  than  a  curative  opera- 
tion. In  selected  cases  in  which  the  attachment  is  directly  to 
the  bone,  and  especially  when  lateral  motion  is  checked  by 
arthrodesis,  the  results  are  very  satisfactory.  The  improvement  in 
functional  ability  is  immediately  shown  in  the  improved  circula- 
tion and  size  of  the  limb.  In  some  cases  of  this  class  the 
transferred  muscle  is  apparently  undergoing  an  adaptive  hyper- 
trophy. It  is  needless  to  say  that  such  results  are  favored  by 
massage  and  by  appropriate  exercises.  Even  in  those  cases  in 
which  the  result  is  far  from  satisfactory,  some  improvement  is 
usually  apparent. 

The  principles  of  tendon  transplantation  may  be  applied  in 
other  situations.  For  example,  the  sartorius  or  the  tensor  vagiuse 
femoris  muscle  may  be  attached  to  the  tendon  of  a  paralyzed 
quadriceps  extensor  muscle  for  the  purpose  of  restoring  in  some 
degree  the  ability  to  extend  the  leg. 

The  flexor  muscles  may  be  transplanted  to  the  extensor  aspect 
of  the  thigh  to  overcome  persistent  contracture,  the  result  of 
spastic  paralysis.     (See  page  615.) 


DEFORMITIES  OF  THE  FOOT.  823 

The  operations  for  the  relief  of  hemiplegic  deformity  of  the 
hand  have  been  mentioned.      (See  page  613.) 

Tendon  Splicing.  Division  and  overlapping  of  the  tendons  of 
paralyzed  muscles  may  be  employed  with  advantage  in  certain 
instances.  For  example,  in  complete  paralysis  of  all  the  dorsal 
flexors  of  the  foot,  each  tendon  may  be  shortened  and  attached 
to  the  anterior  ligament ;  thus  the  toe-drop  may  be  remedied  or 
reduced  to  such  an  extent  that  the  deformity  may  interfere  but 
slightly  with  locomotion.  As  a  rule,  however,  apparatus  must 
be  employed  to  prevent  a  recurrence  of  the  deformity  unless  it 
be  combined  with  arthrodesis. 

Arthrodesis. 

The  removal  of  the  cartilaginous  surfaces  of  articulating  bones 
and  thus  inducing  anchylosis  for  the  relief  of  paralytic  deformi- 
ties of  the  foot,  was  first  performed  by  Albert,  of  Vienna,  in 
1878.  As  applied  to  the  foot,  it  is  of  special  service  in  those 
cases  in  which  practically  no  muscular  power  remains,  the  so- 
called  dangle-foot.  It  may  be  of  service,  also,  in  cases  of 
less  disability,  as  in  equinus  or  calcaneus,  when  the  patient  is 
unable  to  provide  himself  with  apparatus  or  desires  to  dispense 
with  it. 

The  operation  consists  in  opening  the  joint  and  removing  the 
cartilage  from  the  apposed  surfaces  of  the  bones,  then  sewing  or 
nailing  them  to  one  another,  or  simply  fixing  the  parts  in  a  plaster 
bandage  until  union  has  taken  place.  If  the  case  is  one  of  simple 
calcaneus  or  equinus,  without  lateral  deviation,  the  operation 
may  be  limited  to  the  ankle-joint,  which  may  be  opened  from  the 
back  or  front  side,  as  seems  preferable.  As  has  been  stated,  the 
usual  incision  is  about  two  inches  in  length  over  the  front  of  the 
ankle-joint.  The  foot  is  then  plantar  flexed  and  the  cartilage  is 
thoroughly  removed  from  the  articulating  surfaces  with  a  ihin 
chisel  or  knife.  The  wound  is  then  closed,  and  the  denuded 
bones  are  forced  into  accurate  apposition  and  fixed  by  a  plaster 
bandage.  As  soon  as  possible  the  patient  is  encouraged  to  use 
the  foot.  As  a  rule,  in  cases  of  complete  paralysis  of  the  anterior 
group  simple  anchylosis  at  the  ankle-joint  is  not  sufficient  to  pre- 
vent the  toe-drop,  and  it  is  well  to  destroy  the  mediotarsal  joint 
also.  A  convenient  method  is  to  remove  the  cartilaginous  sur- 
face of  the  astragalonavicular  and  calcaneocuboid  articulations, 
together  with  a  thin  wedge  of  bone,  base  uppermost.  In  some 
instances  the  tendons  of  the  paralyzed  muscles  are  shortened  to 


824  OBTHOPEDIC  SUEGEEY. 

aid  in  retaining  the  foot  in  the  improved  position.  This,  how- 
ever, is  of  minor  importance.  The  operation  should  be  performed 
under  the  Esmarch  bandage,  and  the  limb  should  be  elevated  for 
a  time  to  prevent  the  subsequent  bleeding  from  the  bones. 

Arthrodesis  and  Tendon  Transplantation.  As  has  been 
mentioned,  arthrodesis  may  be  combined  with  tendon  transplanta- 
tion. For  example,  the  astragalonavicular  joint  may  be  obliter- 
ated if  the  foot  is  inclined  toward  valgus,  union  being  obtained  in 
a  position  of  adduction.  Or,  if  the  attitude  is  one  of  varus  the 
foot  must  be  held  in  abduction  during  the  process  of  consolida- 
tion. In  some  iustances  the  arthrodesis  is  obtained  by  removing 
a  thin  cuneiform  segment  from  the  inner  or  outer  aspect  of  the 
foot,  including  the  joint.  In  the  treatment  of  varus  deformity 
this  may  include  the  calcaneocuboid  joint  also.^  The  operation 
for  the  relief  of  calcaneus  deformity  has  been  described.  (See 
page  808.) 

The  improvement  in  the  gait,  obtained  by  the  rectification  of 
deformity,  and  by  fixation  of  the  foot,  after  arthrodesis,  is  often 
very  marked,  and  in  many  instances  support  may  be  discarded  ; 
but,  in  early  childhood  at  least,  the  patients  should,  if  possible, 
be  kept  under  observation,  in  order  that  recurrence  of  deformity 
may  be  prevented. 

Arthrodesis  is  also  performed  at  the  knee  and  at  the  elbow- 
joints  and  wrist-joints  for  the  purpose  of  fixing  the  part  in  a  useful 
attitude.  The  operation  is,  of  course,  limited  to  cases  of  hopeless 
paralysis,  and  it  is  more  satisfactory  to  the  older  than  the  younger 
class  of  patients,  because  the  liability  to  recurrence  of  deformity 
is  less.  Arthrodesis  at  the  shoulder-joint  is  of  service  when  the 
humeroscapular  muscles  are  paralyzed,  especially  in  those  cases 
in  which  the  muscles  that  move  the  scapula  retain  their  power, 
since  anchylosis  adds  to  the  effectiveness  of  the  arm  muscles. 
The  joint  may  be  opened  by  an  incision  along  the  anterior  lower 
border  of  the  deltoid.  The  cartilaginous  surfaces  are  removed, 
and  the  humerus  is  then  fixed  in  close  contact  with  the  glenoid 
surface  of  the  scapula  by  a  drill  or  by  sutures  until  union  is  firm. 

1  Whitman.    Journal  of  American  Orthopedic  Association,  1903,  No.  1,  vol.  i. 


INDEX. 


ABDUCTION  in  extreme  types  of 
weak  foot,  676 
Abduction  in  hip  disease,  301 
Absence  of  clavicle,  233 
of  ribs,  233 
of  vertebrae,  230 
Absent  patella,  436 

treatment  of,  436 
Abscess    in    acute    osteomj^elitis    of 
spine,  130 
complicating  tuberculous  disease  of 
spine    in    different    re- 
gions, 106 
treatment  of,  108 
as  coiTipli cation  in  tuberculous  dis- 
ease of  spine,  104 
statistics  of,  104 
in  different  regions  of  spine,  106 
treatment  of,  108 

aspiration  in,  110 
injections  in,  110 
pelvic,    in    tuberculous   disease    of 

lower  region  of  spine,  44 
as  secondary  symptom  in  tubercu- 
lous disease  of  spine,  30 
in  thoracic  region  in  tuberculous 

disease  of  spine,  55 
in  tuberculous  disease  of  hip-joint, 
371 
statistics  of,  371 
Koenig's,  372 
treatment  of,  374 

exploratory  operations  in, 
376 
of  knee-joint,  419 
statistics  of,  419 
treatment  of,  420 
Achillobursitis,  713 
anterior,  713 
etiology  of,  713 
pathology  of,  714 
posterior,  715 
symptoms  of,  713 
treatment  of,  714 
operative,  715 
Achillodynia.   »See  Achillobursitis,  713 
Achondroplasia.    See  Chondrodystro- 

phia,  492 
Acquired  calcaneovalgus,  812 
treatment  of,  812 
calcaneovarus,  812 

treatment  of,  812 
cerebral  paralysis,  606-611 


Acquired  luxation  of  the  clavicle,  233 
treatment  of,  233 
simple  valgus,  814 
talipes,  794 
calcaneus,  804 

development  of  deformity  in, 

804 
symptoms  of,  805 
treatment  of,  805 
operative,  807 

Whitman's  oi^eration,  810 
Willett's  operation,  808 
equinovalgus,  813 
equinovarus,  812 
equinus,  796 
etiology  of,  797 
prognosis  of,  799 
symptoms  of,  798 
treatment  of,  799 
arthrodesis  in,  803 
immediate  correction  of  de- 
formity in,  801 
tonic  effect  of,  801 
Shaffer    extension    shoe    in, 
800 
torticollis,  631 
acute,  631 
Acromegalia,  500 

diagnosis  of,  500 
Active  congestion  as  means  of  treat- 
ment of  joint  affections,  261 
Acute  acquired  torticollis,  631 
anterior  poliomyelitis,  583 

causes  of  deformity  in,  590 
functional  use,  591 
gravity,  590 
habitual  posture,  591 
muscular  action,  590 
subluxation,  591 
deformities  of  neck  in,  592 
secondary,  in,  593 
of  trunk  in,  592 
of  upper  extremity  in,  592 
diagnosis  of,  586 

differential,  587 
effects  of  paralysis  of  different 
muscles  upon  function,  589 
etiology  of,  584 
pathology  of,  583 
prognosis  of,  588 

electrical  test  in,  588 
retardation  of  growth  in,  594 
statistics,  age  at  onset  of,  584 


826 


INDEX. 


Acute  anterior  poliomyelitis,  statistics 
of  distribution  of  paralysis, 
585 
symptoms  of,  585 
treatment  of,  595 

mechanical,     principles    of, 

595 
operative,  601 

arthrodesis  in,  603 
osteotomy  in,  604 
of  paralj'sis  of  arm,  600 
of    anterior   leg   muscles, 

596 
of  muscles  of  hip,  599 
of  posterior  leg  muscles, 

596 
of  thigh  muscles,  598 
of  paralytic  scoliosis,  600 
tendon   transplantation   in, 
602 
Acute  arthritis  of  infancy,  270 
etiology  of,  270 
prognosis  of,  271 
statistics  of,  271 
symptoms  of,  271 
treatment  of,  271 
Acute  epiphysitis  at  hip-joint,  392 
infectious    arthritis    of     hip-joint, 

392 
osteomyelitis,  272 
of  spine,  130 

symptoms  of,  130 
treatment  of,  131 
Acute  tuberculous  arthritis,  272 
Adduction  in  hip  disease,  302 
Amputation  in  tuberculous  disease  of 

knee-joint,  423 
AnchAdosis,  286 
etiology  of,  286 
pathology  of,  286 
prevention  of,  286 
treatment  of,  286 

forcible  correction  in,  288 
passive  motion  in,  288 
X-ray  in,  289 
Ankle-joint,   tuberculous  disease   of, 

440 
Ankle,  sprain  of,  450 
chronic,  453 

treatment  of,  453 
symptoms  of,  450 
treatment  of,  450 

adhesive  plaster  in,  451 
Ankle,  tenosynovitis  at,  454 

treatment  of,  455 
Ankle,  tuberculous  disease  of,  440 
deformity  of,  443 
diagnosis  of,  444 
pathology  of,  440 
physical  examination  in,  443 
prognosis  of,  448 
statistics  of,  440 
of  age,  441 
of  results,  448 
situation  of  disease,  441 


Ankle,  tuberculous  disease  of,   statis- 
tics of,  table  of    age   at  in- 
cipiency,  442 
subastragaloid  disease,  444 
symptoms  of,  442 
treatment  of,  446 
operative,  447 
reduction   of   deformity   in, 
446 
Anterior  achillobursitis,  713 
bow-leg,  580 

displacement    of    the    tibia.      See 
Congenital  genu  recurvatum,  434 
metatarsalgia,  704 
etiology  of,  705 
influence  of  shoe  in  causing  pain 

in,  708 
patholog}'  of,  705 
treatment  of,  710 
operative,  711 
Anterior   poliomyelitis,    acute.       See 

Acute  anterior  poliomyelitis,  583 

Anterior  shoulder  brace  in  treatment 

of  tuberculous  disease  of  spine,  76 

Anteroposterior  deformities  of  spine, 

224 

kj^phosis,  224 

treatment  of,  227 
lordosis,  228 

treatment  of,  228 
Arborescent    synovial     tuberculosis, 

252 
Arthrectomjr  in  treatment  of  tuber- 
culous disease  of  knee- 
joint,  420 
results  of,  421 
statistics  of,  421 
Arthritis,  acute,  of  infancy,  270 
etiology  of,  270 
prognosis  of,  271 
statistics  of,  271 
symptoms  of,  271 
treatment  of,  271 
infectious,  of  hip-joint,  392 
tuberculous,  272 
complicating    infectious    diseases, 
269 
prognosis  of,  270 
spontaneous  dislocation  in, 

270 
treatment  of,  269 
Arthritis  deformans,  274,  396 
symptoms  of,  397 
treatment  of,  397 
gonorrhoeal,  267 
distribution,  267 

statistics  of,  267 
of  hip-joint,  394 
symptoins  of,  267 
treatment  of,  268 
varieties  of,  268 
Arthritis  of  knee,  infectious,  428 
of  spine,  infectious,  135 

treatment  of,  135 
ptierperal,  269 


INDEX. 


827 


Arthritis,  rheumatoid,  279 
etiology  of,  282 
treatment  of,  282 
subacute,  of  hip-joint,  393 
Arthrodesis,  description  of  operation, 
823 
for  relief  of  paralytic  deformities  of 

foot,  823 
and  tendon  splicing,  824 
in   treatment   of    acquired   talipes 
ecjuinus,  803 
of   acute   anterior  poliomyelitis, 

603 
of  rigid  weak  foot,  697 
Arthrotomy  in  treatment  of  congen- 
ital dislocation  at  hip,  527 
Astragalectomy  in  treatment  of  tal- 
ipes, 781 
Astragaloscaphoid  joint,  tuberculous 

disease  of,  449 
Asj'mmetrical  development,  234 
Ataxia,  hereditary,  619 
Atrophy  of  bone,  241 

progressive  muscular,  616 
in  tuberculous  disease  of  hip-joint, 
307 
Rrackett's  statistics  of.  308 


BACK  knee.   See  Genu  recurvatum, 
432 
Back,  lower  part  of,  pain  in,  144 
Bands,  constricting,  793 
Baseball   linger.      See   Mallet   finger, 

484 
Bier's  treatment  of  tuberculous  dis- 
ease of  joints,  259 
of  knee-joint,  418 
Bilateral  coxa  vara,  541 

tuberculous    disease    of    hip-joint, 
369 
treatment  of,  369 
Billroth  splint  in  treatment  of  tuber- 
culous disease  of  knee-joint,  414 
Bone,  atrophv  of,  241 
Bow-leg,  553" 
anterior,  580 

symptoms  of,  580 
treatment  of,  582 
etiology  of,  554 

predisposition  to  deformity,  555 
outgrowth  of  deformity  of,  557 
statistics  of,  553 

relative  frequency  of,  553 
table  of,  554 
treatment  of,  558 
Brace  in  treatment  of  weak  foot,  685 

construction  of,  685 
Bradford  frame  for  horizontal  fixa- 
tion   in    treatment    of    Pott's 
disease,  68 
modification  of,  69 
Bursa,  enlargement  of  superficial  pre- 
tibial,  430 


Bursitis,   chronic,  at   shoulder-joint, 

469 
gluteal,  395 
iliopsoas,  395 

treatment  of,  396 
prepatellar,  of  knee,  429 

treatment  of,  429 
pretibial,  429 

symptoms  of,  429 

treatment  of,  430 


CALCANEOBURSITIS,  716 
treatment  of,  716 
Calcaneovalgus,  789 
acquired,  812 

treatment  of,  812 
Calcaneovarus,  789 
acquired,  812 

treatment  of,  812 
Caliper  brace  in  treatment  of  tuber- 
culous disease  of  knee-joint,  417 
Calot's  operation   of   forcible  reduc- 
tion   of    deformit}^ 
of    Pott's    disease, 
123 
selection  of  cases  for, 

121 
statistics    of    results 
of,  120 
Caries  sicca,  253 
Cavus,  789 

Cerebral  paraly.sis  of  childhood,    606 
acquired,  611 

deformities  of,  611 
disability  in,  611 
loss  of  growth  in,  611 
congenital  weakness  in,  609 
deformities  of,  610 
etiology  of,  606 
prognosis  of,  615 
statistics   of    distribution    of, 

606 
symptoms  of,  608 
mental,  609 
motor,  608 
treatixient  of,  612 
of  hemiplegia,  612 
of  paraplegia,  614 
varieties  of,  606 
acquired,  606 
congenital,  606 
Cervical  opisthotonos,  646 
Charcot's  disease,  284 
diagnosis  of,  285 
distribution  of,  286 
pathology  of,  284 
statistics  of,  285 
symptoms  of,  285 
treatment  of,  285 
Chest,  deformities  of,  230 
minor,  232 
flat,  230 

treatment  of,  230 


828 


INDEX. 


Chest,  funnel,  232 
pigeon,  231 

treatment  of,  231 
Chondrodystrophia,  492 
etiology  of,  492 
patholog}^  of,  492 
prognosis  of,  494 
treatixient  of,  494 
Chronic    bursitis    at    shoulder-joint, 

469 
Clavicle,  absence  of,  233 
acquired  luxation  of,  233 

treatment  of,  233 
defect  of,  233 
Club-foot,  hysterical,  621 

non-deforming.        See    Contracted 
foot,  699 
Club-hand,  479 
etiology  of,  479 
statistics  of,  479 
treatment  of,  481 
varieties  of,  479 
Congenital  cerebral  paralysis,  606 
contraction  of  fingers,  482 

at  knee,  439 
deformities  at  elbow,  477 
at  wrist,  479 
Congenital  dislocation  of  hip,  502 
anterior,  symptoms  of,  511 
bilateral,  symptoms  of,  510 
diagnosis  of,  511 

differential,  512 
etiology  of,  507 
pathologv  of,  503 
statistics"  of,  502 
supracotyloid  displacement  in, 

511 
symptoms  of,  508 

general,  510 
treatment  of,  513 
arthrotomy  in,  527 

description  of,  527 
in  infancy,  526 
Lorenz  operation  in,  514 
description  of,  515 
prognosis  of,  523 
of  older  subjects,  526 
open  operation  in,  530 
description  of,  531 
statistics  of,  532 
osteotomy  in,  529 
palliative,  534 
variation  in,  527 
unilateral,  symptoms  of,  508 
Congenital    dislocation    of    shoulder, 
472 
treatment  of,  472 
displacements  of  fingers,  483 

of  patella,  436 
elevation  of  scapula,  228 
lateral  curvature  of  spine,  167 

cases  of,  167 
subluxation  of  hip,  534 
talipes,  738 


Congenital  calcaneus,  788 
equinovalgus,  789 
equinus,  788 
varus,  787 
torticollis,  626 
Congestion,  active,  as  means  of  treat- 
ment of  joint  affections,  261 
passive,  as  means  of  treatment  of 
joint  affections,  259 
Constricting  bands,  793 
Contour   and    flexibility  of     normal 
spine,  31 
of  spine,  variations  in,  223 
Contracted  foot,  699 
etiology  of,  699 
symptoms  of,  700 
treatment  of,  702 
operative,  703 
Contractions,  general,  at  knee,    439 
prognosis  of,  439 
treatment  of,  439 
Corsets  in  treatment  of  tuberculous 

disease  of  spine,  95 
Coxa  valga,  552 
vara,  535 

bilateral,  541 

symptoms  of,  541 
diagnosis  of,  543 
etiology  of,  537 

mechanical    predisposition    to 
deformity,  537 
other  varieties  of,  542 
pathology  of,  536 
statistics  of,  538 
symptoms  of,  539 

mechanical  effects,  539 
physical  effects,  540 
traumatic,  548 
in  adult  life,  551 
treatment  of,  550 
treatment  of,  545 
operative,  546 

cuneiform  osteotomy  in,  547 
forcible  abduction  in,  546 
linear  osteotomy  in,  546 
Cretinism,  494 
Cubitus  valgus,  477 

varus,  477 
Cuneiform  osteotomy  in  treatment  of 
coxa  vai'a,  547 
of  talipes,  782 
Cysts  of  femur,  396 

in  popliteal  region,  430 


DEFECT  of  clavicle,  233 
Depression   of   neck   of  femur. 
See  Coxa  vara,  535 
Development,  asjanmetrical,  234 

normal,  table  of,  235 
Diagnosis  of  acromegalia,  500 

of     acute    anterior     poliomvelitis, 

586 
of  Charcot's  disease,  285 


INDEX. 


829 


Diagnosis  of  congenital  dislocation  at 
hip-joint,  511 
of  coxa  vara,  543 
differential,   of  lumbar  Pott's  dis- 
ease in  infancy,  50 
of    tuberculous    disease    of    hip- 
joint,  319 
of  disease  of  upper  region  in  tuber- 
culous disease  of  spine,  61 
of  joint  disease,  256 
of  lateral  curvature  of  spine,  175 
posture  in,  175 
mobility  in,  175 
of  malignant  disease  of  spine,  130 
of    pseudohypertrophic     muscular 

paralysis,  618 
of  sacro-iliac  disease,  147 
of  syphilis  of  spine,  129 
•  of  torticollis,  635 
of    tuberculous    disease    of   ankle- 
joint,  444 
of  knee-joint,  408 
of  spine,  46-64 

Roentgen  rav  as  means  of, 
65 
of  weak  foot,  672 
Diphtheritic  paralysis  with  torticollis, 

646 
Diseases  of  nervous  system,  583 

statistics  of,  583 
Dislocation,  spontaneous,  in  arthritis 
complicating     infectious     dis- 
eases, 270 
of  hip-joint,  393 
Displacement  of  the  peronei  tendons, 
727 
treatment  of,  727 
of  semilunar  cartilage,  431 
treatment  of,  432 
Distortions  of  fingers,  483 
general  rhachitic,  582 
of  limb  in  tuberculous   disease   of 
hip-joint,  301 
Divisions  of  spine,  32 

of  tendo  Achillis   in   treatment   of 
talipes,  773 
Dollinger's  statistics  of  retardation  of 
growth  in  tuberculous  disease 
.      of  hip,  311 

of  situation  of  tuberculous  dis- 
ease of  spine,  24 
Drop-finger.     See  Mallet  finger,  484 
Dry  caries,  253 
Dupuytren's  contraction,  484 
etiology  of,  485 
pathology  of,  484 
symptoms  of,  485 
treatment  of,  485 
Dystrophy,  muscular,  617 


ELBOW,  congenital  di'forniities  at, 
477 
Elbow,  tuberculous  disease  of,  460 
-joint,  tuberculous  disease  of,  460 


Elbow-joint,    tuberculous   disease    of, 
pathology  of,  460 
prognosis  of,  462 
statistics  of,  460 

age  at  incipiency,  461 
symptoms  of,  461 
treatment  of,  461 
excision  in,  464 

statistics  of  final  results, 
464 
operative,  464 
reduction   of   deformity   in, 
462 
Elongation    of   ligamentum    patellae, 
438 
etiology  of,  438 
sj'mptoms  of,  438 
treatment  of,  438 
Enlargement  of   superficial  pretibial 

bursa,  430 
Epiphysitis,  acute,  at  hip-joint,  392 
symptoms  of,  392 
treatment  of,  392 
Equinovalgus,  traumatic,  814 
Erythromelalgia,  717 
Excision  of  elbow  in  tuberculous  dis- 
ease of  elbow-joint,  464 
in    tuberculous    disease    of    knee- 
joint,  422 
results  of,  423 
statistics  of,  423 
Exostoses  of  foot,  727 
Extra-articular  disease,  395 
of  knee,  419 

FEET,  congenital  oedema  of,  793 
Femur,  bending  of  neck  of.    See 
Coxa  vara,  535 
Femur,  cysts  of,  396 

depression  of  neck  of.     See  Coxa 

vara,  535 
fracture  of  neck  of,  in  adult  life, 
551 
Finger,  "baseball."     See  Mallet  fin- 
ger, 484 
congenital  contraction  of,  482 
treatment  of,  482 
displacements  of,  483 
distortions  of,  483 
drop.     See  Mallet  finger,  484 
jerking.     See  Trigger  finger,  483 
mallet,  484 

snapping.     See  Trigger  finger,  483 
trigger,  483 
webbed,  482 
etiology  of,  483 
treatment  of,  483 
Flat  chest,  230 

treatment  of,  230 
foot.     See  Weak  foot,  664 
Fcx'tal    rhachitis.      See    Chondrodys- 

trophia,  492 
Foot  in  activity,  650 
arches  of,  647 


830 


INDEX. 


Foot    considered    as    a    mechanism, 
660 
contracted,  699 
etiolog-v  of,  699 
symptoms  of,  700 
treatment  of,  702 
operative,  703 
Foot  exostoses  of,  727 

flat.     See  Weak  foot,  664 
functions  of  muscles  of,  658 
general  description  of,  647 
hollow.     See  Contracted  foot,  699 
improper  postures  of,  651 
movements  of,  651 
as  a  passive  support,  649 
Foot,  rigid,  690 

treatment  of,  690 

forcible  overcorrection  in,  690 
manipulation  in,  693 
varieties  of,  695 
treatment  of,  696 
operative,  697 
plaster  strapping  in,  696 
Thomas',  696 

arthrodesis  in,  697 
splay,     See  Weak  foot,  664 
tables  of  relative  strength  of  mus- 
cles of,  659 
weak,  664 

anatomy  of,  664 
in  childhood,  678 

symptoms  of,  678 
diagnosis  of,  672 
etiology  of,  669 
extreme  types  of,  676 

persistent  abduction  in,  676 
pes  planus,  676 
irregular  forms  of,  680 
limitation  of  motion  and  muscu- 
lar spasm  in,  676 
pathology  of,  668 
statistics  of,  669 
symptoms  of,  670 
treatment  of,  682 
attitudes  in,  683 
brace  in,  685 

construction  of,  685 
exercises  in,  684 
the  shoe  in,  682 
support  in,  684 
varieties  of,  675 
Forcible    manual    correction    of    de- 
formity of  taliijes,  763 
overcorrection  in  treatment  of  rigid 
weak  foot,  690 
Fracture  of  metatarsal  bones,  727 
of  neck  of  femur.     See  Traumatic 
coxa  vara,  548 
in  adult  life,  551 
Fragilitas  ossium,  495 
Friedreich's  disease,  619 
Functional  affections  of  joint,  622 

pathogenesis  of  deformitv,  235 
Funnel  chest,  232 


GENU  varmn,  575 
symptoms  of,  576 
Genu  varum,  treatment  of,  578 
by  braces,  578 
expectant,  578 
operative,  579 
Gluteal  bursitis,  395 
Gonorrhoeal  arthritis,  267 
distribution,  267 

statistics  of,  267 
of  hip-joint,  394 
symptoms  of,  267 
treatment  of,  268 
varieties  of,  268 
rheumatism.     See  Gonorrhoeal  ar- 
thritis, 267 
Gout,  rheumatic,  274 
Grattan   osteoclast   in   treatment   of 
talipes,  778 


H^MARTHROSIS,  283 
Htemophilia,  283 
Haemophilia,  treatment  of,  283 
Hallux  flexus.   See  Hallux  rigidus,  718 
rigidus,  718 

etiology  of,  718 
treatment  of,  719 
Hallux  valgus,  722 
etiologv  of,  722 
pathology  of,  722 
symptoms  of,  723 
treatment  of,  723 

Holden  toe-post  in,  723 
operative,  725 
Hallux  varus,  720 

treatment  of,  721 
Hammer-toe,  725 
syniptoms  of,  726 
treatment  of,  726 
Heberden's  nodosities  in  osteoarthri- 
tis, 278 
Heel,  painful,  716 
Hemiplegia,  treatment  of,  612 
Hereditary  ataxia,  619 
High  hip  in  lateral  curvature  of  the 
spine,  156 
shoulder    in    lateral    curvature    of 
spine,  156 
Hip,  congenital  subluxation  of,  534 
Hip  disease.  See  Tuberculous  disease 
of  hip-joint,  291 
hysterical,  620 

-joint,  acute  infectious  arthritis  of, 
392 
epiphysitis  at,  392 
svmptoms  of,  392 
treatment  of,  392 
congenital  dislocation  at,  502 
anterior,  symptoms  of,  511 
bilateral,  s3'mptoms  of,  510 
etiology  of,  507 
diagnosis  of,  511 
differential,  512 


INDEX. 


831 


Hip-joint,    congenital   dislocation    at, 
pathology  of,  503 
statistics  of,  502 
supracotyloid   displacement 

in,  511 
symptoms  of,  508 

general,  510 
treatment  of,  513 
arthrotomy  in,  527 

description  of,  527 
in  infancy,  526 
Lorenz  operation  in,  514 
description  of,  515 
prognosis  of,  523 
of  older  subjects,  526 
open  operation  in,  530 
description  of,  531 
statistics  of,  532 
osteotomy  in,  529 
palliative,  534 
variations  in,  527 
unilateral,  symptoms  of,  508 
gonorrhccal  arthritis  of,  394 
malignant  disease  about,  396 
osteo-arthritis  of,  396 
symptoms  of,  397 
treatment  of,  397 
snapping,  535 

spontaneous  dislocation  of,  393 
subacute  arthritis  of,  393 
traumatism  at,  391 
treatment  of,  391 
Hip,  tuberculous  disease  of,  291 
abscess  in,  371 

significance  of,  373 
statistics  of,  371 
Koenig's,  372 
treatment  of,  374 

exploratory^  operations  in, 
376 
actual  lengthening  of  limb  in, 
313 
shortening  of  limb  in,  309 
in  the  adult,  371 
atrophj^  in,  307 

Brackett's  statistics  of,  308 
bilateral,  369 

treatment  of,  369 
changesof  contourof  hip  in,306 
combined  with  disease  of  other 

parts,  370 
correction     of     deformity    by 

femoral  osteotomy,  382 
deformities     of     other     parts 

caused  bv,  389 
details  of  1000  cases  of,  324 
diagnosis  of,  differential,  319 
anterior  poliomyelitis  in,  319 
coxa  vara  in,  321 
disease  of  bursic  about  joint 

in,  321 
epiphysitis  in,  320 
extra-articular    disease    in, 
320 


Hip,  tuberculous  disease  of,  diagnosis 
of,   differential    hj-sterical 
joint  in,  322 
infectious  arthritis  in,  320 
osteo-arthritis  of  hip  in,  320 
Pott's  disease  in,  321 
rheumatism  in,  320 
sacro-iliac  disease  in,  321 
scurvy  in,  320 
traumatic  coxa  vara  in,  321 
X-ray  as  means  of,  322 
distortion  of  limb  in,  301 
apparent  lengthening,  301 
shortening,  302 
etiology  of.     See  243 
examination  in,  method  of,  313 

physical,  314 
excision  of  hip  in,  377 

Koenig's  method,  377 
statistics  of,  379 

table  of   functional   re- 
sults, 380 
general  sj^mptoms  of,  313 
debility  as,  313 
fever  as,  313 
history  of  case  of,  313 
in  infancy,  370 
Koenig's  statistics  of,  304 
local  signs  of,  318 
measurements  of,  315 
method   of   estimating   degree 
of  distortion  of  the 
limb,  316 
Lovett's  table,  316 
Kingsley's  table,  318 
of  recording  case  of,  322 
formula  used,  323 
mortality  in,  384 
statistics  of,  384 
causes  of  death,  385 
"natural  cure"  in,  303 
pathology  of,  291 
prognosis  of,  384 
as  to  function,  387 
statistics  of,  387 
reduction  of  deformity  in  re- 
sistant cases  of,  381 
relative  frequency  of,  295 

statistics  of,  295 
retardation  of  growth  in,  311 
DoUinger's    statistics    of, 

311 
Taylor's  statistics  of,  312 
sinuses  in,  375 

treatment  of,  375 
statistics  of  age  in,  295 
of  sex  in,  295 
side  affected,  296 
symptoms  of,  296 
limp  as,  298 
"  night  cry"  as,  297 
pain  as,  297 
stiffness  as,  298 
treatment  of,  325 


832 


INDEX. 


Hip  tuberculous  disease  of,  treatment 
of,  application  of  spica 
bandage,  345 
of  traction  splint  in,  331 
during  stage  of  recovery,  363 
immediate  reduction  of  de- 
formity in,  348 
Judson's  perineal  crutch  in, 

365 
Lorenz's  spica  in,  347 
mechanical,  327 
high  shoe  in,  331 
perineal  bands  in,  331 
splinting  in,  327 
traction  in,  327 
hip  splint  for,  327 
straps  for,  329 
Taylor's  method  of,  329 
by  plaster  bandage,  345 
practical  combination  trac- 
tion,  stilting,  and  splint- 
ing, 356 
reduction  of  deformity,  lat- 
eral traction  in,  353 
bv    Marsh's     appliance 

^for,  351 
by     Thomas'     method, 

342 
by  traction  brace,  333 
by  weights  and  puUevs, 
"350 
relative    efficiency    of    trac- 
tion hip  splint,  334 
traction  and   splinting, 
354 
Taylor's  median  abduction 

brace  in,  364 
Thomas,  338 
brace  in,  339 

modifications  of,  343 
Holden  toe-post  in  treatment  of  hal- 
lux valgus,  723 
Hollow   foot.      See   Contracted   foot, 

699 
Horizontal  fixation  in  treatment  of 
tuberculous      disease 
of  spine,  67 
Bradford  frame  for,  68 

modification  of,  69 
Lorenz    apparatus    for, 

67 
Phelps'  bed  for,  68 
wire  cuirasse  for,  68 
Housemaid's  knee,  429 
Hysterical  club-foot,  621 
deformities,  621 
hip,  620 

diagnosis  of,  620 
joint  affections,  619 
scoliosis,  621 

treatment  of,  621 
spine,  143 

symptoms  of,  143 
treatment  of,  144 


IDIOPATHIC  osteopsathyrosis,  495 
Iliopsoas  bursitis,  395 
treatment  of,  396 
Incurvation  of  neck  of  femur.     See 

Coxa  vara,  535 
Infantile  paralj'sis.     See  Acute  ante- 
rior poliomyelitis,  583 
scorbutus,  494 
pathology  of,  494 
sjanptoms  of,  494 
treatment  of,  495 
talipes,  749 
Infectious  arthritis  of  knee,  428 
of  spine,  135 

treatment  of,  135 
Injur)^  of  knee  in  childhood,  427 
of  spine,  131 
of  tibial  tubercle,  430 
Internal  derangement  of  knee-joint, 

430 
Irregular  forms  of  weak  foot,  680 


JERKING  finger,  483 
Joint  affections,   hysterical,  619 
Joints,  neurotic,  622 

functional  affections  of,  622 
syphilitic  diseases  of,  263 

gonorrhoeal  arthritis,  267 
distribution,  267 

statistics  of,  267 
symptoms  of,  267 
treatment  of,  268 
varieties  of,  268 
puerperal  arthritis,  269 
treatment  of,  265 
Judson  brace  in  treatment  of  talipes, 

754 
Julius  AVolff's  method  of  treatment  of 

talipes,  774 
Jur}'  mast  in  treatment  of  tubercu- 
lous disease  of  spine,  86 


KINGSLEY'S  table  for  estimating 
degree  of  distortion  in  tuber- 
culous disease  of  hip -joint, 
318 
Knee,  back.  See  Genu  recurvatum, 
432 
bui'sse  at,  430 

congenital  contraction  at,  439 
cysts  at,  430 
deformities  of,  434 
displacement  of  a  similunar  cartilage 
in,  431 
injury  as  cause  of,  431 
treatment  of,  432 
Knee,  general  contractions  at,  439 
prognosis  of,  439 
treatment  of,  439 
enlargement  of  superficial  pretibial 

bursa  of,  430 
housemaid's,  429 


INDEX. 


833 


Knee,  infectious  arthritis  of,  428 
injury  of,  in  childhood,  427 
injury  of  tibial  tubercle,  430 
Knee-joint,  loose  bodies  in,  431 
internal  derangement  of,  430 
non-tuberculous       affections       of 

427 
malformations  of,  434 
etiology  of,  435 
treatment  of,  435 
osteo-arthritis  of,  428 

treatment  of,  428 

prepatellar  bursitis  of,  429 

treatment  of,  429 

Knee,  pretibial  bursitis  of,  429 

symptoms  of,  429 

treatment  of,  430 

snapping,  438 

treatment  of,  439 
synovitis  of,  427 
chronic,  428 
treatment  of,  427 
Knee,  tuberculous  disease  of,  399 
abscess  in,  419 
statistics  of,  419 
treatment  of,  420 
actual  lengthening  of  limb  in, 
407 
statistics  of,  408 
shortening  of  limb  in,  407 
statistics  of,  407 
arthrectomV  in  treatment    of, 
420" 
results  of,  421 
statistics  of,  421 
diagnosis  of,  408 

differential,  408 
distortions  of,  primary,  404 

secondary,  405 
etiology  of,  401 
operations   for   relief   of   final 

deformity,  423 
pathology  of,  399 
prognosis  of,  423 

statistics,    course,   and  out- 
come of,  423 
Gibney's,  423 
of  results,  424 
statistics  of,  401 

age  at  incipiency,  402 
symptoms  of,  402 
synovial  tuberculosis  in,  420 

treatment  of,  420 
treatment  of,  409 
accessory,  417 

Bier's  treatment,  418 

cautery  as,  417 

ichthyol      ointment      as, 

417 
X-ray  as,  417 
amputation  in,  423 
liillroth  splint  in,  413 
caliper  brace  in,  417 
during  convalescence,  418 


Knee,   tuberculous    disease  of,    treat- 
ment of,  excision  in,  422 
results  of,  423 
statistics  of,  423 
forcible    correction    by    re- 
verse leverage,  412 
mechanical,  414 
operative    intervention    in, 

419 
plaster  bandage  in,  411 
reduction   of   deformity   in, 

410 
Thomas  knee  brace  in,  414 
traction  in,  412 
Knock-knee,  553 

combined  with  bow-leg,  565 

with    general    rhachitic    distor- 
tions, 565 
effects  of  deformity  of,  564 
etiology  of,  554 

predisposition   to   deformity   in, 
555 
measurements  of  deformity  in,  567 
outgrowth  of  deformity  of,  557 
patholog}^  of,  566 
secondary  deforinities  accompany- 
ing, 564 
statistics  of,  553 

relative  frequency  of,  553 
table  of,  554 
time  of  onset,  554 
treatment  of,  567 
by  braces,  570 
duration  of,  571 
exercise  in,  569 
expectant,  567 
Lorenz's,  575 
manipulation  in,  568 
operative,  572 
osteoclasis,  573 
osteotomy  in,  572 
cuneiform,  573 
plaster  bandage  in,  572 
posture  in,  569 
Thomas  brace  in,  570 
Wolff's.  574 
unilateral,  565 
Kyphosis  of  adolescents,  141 


LAMINECTOMY   in  treatment  of 
Pott's  paraplegia,  118 
Laminectomy  in  treatment  of   Pott's 

paraplegia,  statistics  of,  118 
Landmarks  of  spine,  34 
Late  rickets,  492 
Lateral  curvature  of  spine,  149 

changes  in  anteroposterior  con- 
tour in,  155 
compensatory    deformity    in, 

165 
congenital,  167 
cases  of,  167 
diagnosis  of,  175 


53 


834 


INDEX. 


Lateral  curvature  of  spine,  diagnosis 
of  mobility  in,  175  | 

posture  in,  175 
due  to  occupation,  166 
etiology  of,  161 

hereditary  influence  in,  169       i 
high  hip  in,  156 

shoulder  in,  156 
incidental,  166 
lateral  deviation  in,  153 
occupation    as    inducing    de- 
formity, 170 
statistics  of,  170  ; 

pathology  of,  156  ! 

prevention  of  deformity  in,  180 
prognosis  of,  177 
records  of,  177 
rhachitic,  168 

statistics  of,  169 
rotation  in,  153 
secondary   to   deformity  else- 
whei-e,  165 
to    disease    within    thoracic 

walls,  166 
to  paralysis,  166 
statistics  of  age  in,  163 

of  relatiA'e  frequency  of,  161 
of  sex  in,  162 
symptoms  of,  174 
treatment  of,  181 
duration  of,  221 
exercises  in,  185-201 
muscle  building,  209 
Teschner's,  187 
forcible    correction    of    de- 
formity in,  217 
general,  221 
high  shoe  in,  221 
posture  in,  185 
Volkmann  seat  in,  221 
varieties  of  deformity  in,  173 
Ligamentum  patella^,   elongation  of, 
438 
etiology  of,  438 
symptoms  of,  438 
treatment  of,  438 
Linear    osteotomy    in    treatment    of 

coxa  vara,  546 
Loose  bodies  in  knee-joint,  431 
Lorenz  apparatus  for  horizontal  fixa- 
tion in  treatment  of  Pott's  dis- 
ease, 67 
operation  for  congenital  dislocation 

at  hip,  514 
spica  bandage  in  treatment  of  tu- 
berculous   disease    of    hip-joint, 
347 
treatment  of  knock-knee,  575 
Lovett's  table  for  estimating  degree 
of  distortion  in  tuberculous  disease 
of  hip-joint,  316 
Lumbar    Pott's    disease    in    infanc}-, 
peculiarities  of,  49 
diagnosis,  differential,  of,  50 


MALFORMATIONS  of  knee,  434 
etiology  of,  435 
Malformations  of  knee,  treatment  of, 

435 
Malignant  disease  about  hip-joint,  396 
of  spine,  129 

diagnosis  of,  130 
statistics  of,  129 
^Nlalleotomv  in  treatment  of  talipes, 

772 
Mallet  finger,  484 

Marsh's  appliance  for  reduction  of  de- 
formity in  tuberculous  disease  of 
hip-joint,  351 
Metatarsal  bones,  fracture  of,  727 
Metatarsalgia,  anterior,  704 
etiology  of,  705 
influence  of  shoe  in  causing  pain 

in,  708 
pathology  of,  705 
treatment  of,  710 
operative,  711 
Metzger-Goldthwait     apparatus     for 
correction   of   deformit}'   of   Pott's 
disease,  123 
Mollifies  ossium.      See  Osteomalacia, 

496 
Morbus  coxa>.     See  Tuberculous   dis- 
ease of  hip-joint,  291 
Morton's     neuralgia.      See     Anterior 

metatarsalgia,  704 
Muscles,    pectoral,    defective    forma- 
tion of,  233 
Muscular  dystrophy,  617 
Myelopathic  paralysis,  616 
Myopathic  paralysis,  617 


""IVTATURAL  cure"  in  tuberculous 

XN  disease  of  hip-joint,  303 
Nervous  system,  diseases  of,  583 
Neuralgia,  plantar,  717 

treatment  of,  717 
Neuritis,  619 
Neurotic  joints,  622 
spine,  142 

symptoms  of,  143 
treatment  of,  143 
Non-deforming  club-foot.      See  Con- 
tracted foot,  699 
Non-tuberculous  affections  of  knee- 
joint,  427 
deformities  of  knee-joint,  427 


OBSTETRICAL  paralysis,  473 
treatment  of,  474 
Ocular  torticollis,  646 
Osteitis  deformans,  141,  498 
Osteo-arthritis,  274 
etiology  of,  277 
Heberden's  nodosities  in,  278 
of  hip-joint,  396 
symptoms  of,  397 


INDEX. 


835 


Osteo-arthritis  of  hip-joint,  treatment 
of,  397 
of  knee,  428 

treatment  of,  428 
pathology  of,  275 
symptoms  of,  277 
treatment  of,  279 
Osteoclasis   in   treatment   of   knock- 
knee,  573 
Osteoclasts  in  treatment  of  talipes, 

778 
Osteomalacia,  496 
in  childhood,  497 
local,  497 
treatment  of,  497 
Osteomyelitis,  acute,  272 
of  spine,  acute,  130 
symptoms  of,  130 
treatment  of,  131 
subacute,  273 
Osteotomy,  cuneiform,  in  treatment 
of  knock-knee,  573 
in  treatment  of  congenital  disloca- 
tion of  hip,  529 
of  knock-knee,  572 
Overlapping  toes,  727 


PAGET'S  disease,  141 
Painful  great  toe-joint,  719 
Painful  heel,  716 

Paralysis,  cerebral,  of  childhood,  606 
acquired,  deformities  of,  611 
disability  in,  611 
loss  of  growth  in,  611 
congenital  weakness  in,  609 
deformities  of,  610 
etiology  of,  606 
prognosis  of,  615 
statistics  of  distribution  of,  606 
symptoms  of,  608 
mental,  609 
motor,  608 
treatment  of,  612 
of  hemiplegia,  612 
of  paraplegia,  614 
varieties  of,  606 
acquired,  606 
congenital,  606 
Paralysis     complicating     tuberculous 
disease  of  spine,  111 
duration  of,  114 
frequency  of,  112 
liability  to,  in  different  re- 
gions, 113 
prognosis  of,  116 
symptoms  of,  114 
time  of  onset  of,  113 
treatment  of,  116 
duration,  126 
local,  119 
operative,  117 

laminectomy,  118 
diplit  ticiit  ic,  with  torticollis,  646 


Paralysis,  infantile.     See  Acute  ante- 
rior poliomyelitis,  583 
myelopathic,  616 
myopathic,  617 
obstetrical,  473 

treatment  of,  474 
pseudohypertrophic  muscular,  618 
diagnosis  of,  618 
treatment  of,  619 
as  secondary  symptom  in  tubercu- 
lous disease  of  spine,  30 
spastic  spinal,  616 
Paralytic  talipes,  tendon   transplan- 
tation for  relief  of,  815 
time  for  operation,  815 
torticollis,  645 
Paraplegia,  treatment  of,  614 
Partial  epiphyseal  separation  in  ado- 
lescence, 551 
Passive  congestion  as  means  of  treat- 
ment of  joint  affections,  259 
Patella,  absent,  436 

congenital  displacement  of,  436 
rudimentary,  436 
slipping,  436 
etiology  of,  436 
symptoms  of,  436 
treatment  of,  437 
operative,  437 
Pectoral    muscles,    defective    forma- 
tion of,  233 
Pectus  carinatum.    See  Pigeon  chest, 
231 
excavatum.    See  Funnel  chest,  232 
Pelvic  abscess,  differential  diagnosis 
of,  49 
in  tuberculous  disease  of  lower 
region  of  spine,  44 
Periarthritis  of  shoulder,  468 
symptoms  of,  468 
treatment  of,  469 
Peronei    tendons,    displacement    of, 
727 
treatment  of,  728 
Pes  planus,  676 

Phelps'  bed  for  horizontal  fixation  in 
treatment  of  Pott's  disease,  68 
operation  in  treatment  of  talipes, 
778 
Pigeon  chest,  231 

treatment  of,  231 
toe,  721 
Plantalgia,  717 
Plantar  neuralgia,  717 
treatment  of,  717 
Plaster  bandage  in  treatment  of  in- 
fantile talipes,  751 
of  knock-knee,  572 
of  tuberculous  disease  of  knee- 
joint,  411 
of  hip-joint,  345 
spica,  Lorenz,  in  treatment  of  tu- 
berculous disease  of  hip-joini, 
347 


836 


INDEX. 


Plaster  corset  in  treatment  of  tuber- 
culous disease  of  spine,  92 
jacket  in  treatment  of  Pott's  dis- 
ease, 82 
application  of,  in  recum- 

bencj',  89 
modifications  of,  93 
strapping  in  treatment  of  weak  foot, 
696 
Poliomyelitis,  acute  anterior,  583 
causes  of  deformitj-  in,  590. 
functional  use,  591 
gravity,  590 
habitual  posture,  591 
muscular  action,  590 
subluxation,  591 
deformities  of  neck,  592 
secondary,  593 
of  trunk,'  592 
of  upper  extreinity  in,  592 
diagnosis  of,  586 

differential,  587 
effects  of  paralysis  of   differ- 
ent muscles  upon  function, 
589 
etiology  of,  584 
pathology  of,  583 
prognosis  of,  588 

electrical  test  in,  588 
retardation  of  growth  in,  594 
statistics  of  ase  at  onset  of, 
584 
of  distribution  of  paralysis, 
585 
symptoms  of,  585 
treatment  of,  595 

mechanical  principles  of,  595 
operatiye,  601 

arthrodesis  in,  603 
osteotomj^  in,  604 
tendon  transplantation  in, 
602 
paralysis     of     anterior     leg 

muscles,  596 
of  paralysis  of  the  arm,  600 
of   paralysis   of   muscles   of 

the  hip,  599 
of  paralysis  of  posterior  leg 

muscles,  596 
of   paralysis  of  thigh   mus- 
cles, 598 
of  paralytic  scoliosis,  600 
Posterior  achillobursitis,  715 
Pott's  disease,  17 

characteristic  angular  deformity 

in,  17 
complications  of,  104 
abscess,  104 

in  different  regions,  106 
statistics  of,  104 
treatment  of,  108 
aspiration  in,  110 
injection  in,  110 
paralysis,  111 


Pott's  disease,   complications  of,  par- 
alysis, duration  of,  114 
frequency  of,  112 
liability  to,  in  different  re- 
gions, 113 
prognosis  of,  116 
symptoms  of,  114 
time  of  onset  of,  113 
treatment  of,  116 
local,  119 
operative,  117 

laminectomy,  118 
description  of,  1 7 
diagnosis  of,  in  general,  64 

Roentgen  ray  in,  65 
examination  in,  regional,  38 

tests  in,  37 
history  of  patient  having,  36 
later  effects  of  deformity  of,  127 
in  lower  region,  38 

characteristic  attitude  in,  39 
diagnosis  of,  46 
differential,  46 

congenital     dislocation 

of  hip,  47 
hip  disease,  48 
lumbago,  46 
sacro-iliac  disease,  46 
sciatica,  46 
strain  of  the  back,  46 
increased  lordosis  in,  39 
lateral   inclination  of  body 

in,  40  _ 

location  of  pain  in,  40 
pelvic  abscess  in,  44 
psoas  contraction  in,  40 
Pott's  disease,  pathology  of,  18 
prognosis  of,  25 
record  of  case  of,  65 
recurrence  of,  127 
relative  frequency  of,  22 

statistics  of,  22 
secondary  deformities  of,  127 
signs  of,  physical,  36 

rational,  35 
statistics  of  age  at  incipiency  of, 
22 
DoUinger's,  24 
of    relative    frequency    of,    in 

different  vertebrae,  24 
results    of    Calot's    operation, 

120 
sex  in,  23 

situation  of  disease,  23 
symptoms  of,  26 
awkwardness  as,  28 
deformity  as,  28 
diagnostic,  27 
general,  31 
pain  as,  27 
secondary,  30 
abscess,  30 
paralysis,  30 
stiffness  as,  28 


INDEX. 


837 


Pott's  disease,  symptoms  of,  weakness 

as,  28 
Pott's  disease  of  thoracic  region,  51 
abscess  in,  55 
attitudes  in,  52 
diagnosis  of,  55 

differential,  56 
kyphosis  in,  54 
muscular  spasm  in,  54 
respiration  in,  52 
treatment  of,  66 

ambulatory  supports  in,  74 
anterior  shoulder  brace  in, 

76 
corsets,  95 
jury  mast,  86 
plaster  corset,  92 
jacket,  82 

application  of,  in  re- 
cumbency, 89 
modifications  of,  93 
Taylor  brace,  74 

head  support,  81 
Thomas'  collar  in  96, 
Weigel's  corset,  95 
duration  of,  126 
forcible  correction  of  deform- 
ity of,  119 
Calot's  operation,  119 
selection  of  cases  for,  121 
gradual  correction  of  deform- 
ity of,  123 
Goldthwait's     method, 

123 
Metzger-Goldthwait  ap- 
paratus for,  123 
horizontal  fixation  in,  67 
Bradford  frame  for,  68 
Lorenz  apparatus  for,  67 
Phelps'  bed  for,  68 
Wire  cuirasse  for,  68 
modifications  of,  69 
indications  for,  by  recumben- 
cy, 98 
special,  of  different  regions, 
99 
of  lower  region  of  spine,  100 
dorsal  region  of  spine,  101 
mechanical,  general  principles 

of,  66 
of  middle   cervical   region   of 

spine,  102 
of  middle  region  of  spine,  102 
of     occipito-axoid     region     of 

spine,  103 
of  upper  dorsal  region  of  spine, 
102 
Pott's  disease  of  upper  region,  57  , 
cervicodorsal  junction,  60 
diagnosis  of,  Gl 
lower  cervical  section,  59 
occipito-axoid  section,  58 
symptoms  of,  58 
Pott's  fracture,  814 


Prepatellar  bursitis  of  knee,  429 

treatment  of,  429 
Pretibial  bursitis,  429 
symptoms  of,  429 
treatment  of,  430 
Progressive  muscular  atrophy,  616 
varieties  of,  616 
myelopathic,  616 
myopathic,  617 
muscular  dj^strophy,  617 
Pseudohypertrophic  muscular  paral- 
ysis, 618 
Psychical  torticollis,  646 
Puerperal  arthritis,  269 


RECURRENT  dislocation  of  shoul- 
der, 476 
Recurrent     dislocation    of     shoulder, 
treatment  of,  476 
operative,  476 
Retardation  of  growth  in  acute  ante- 
rior poliomyelitis,  594 
Retrocalcaneobursitis.      See  Achillo- 

bursitis,  713 
Rhachitic  distortions,  general.  582 
lateral  curvature  of  spine,  168 

statistics  of,  169 
spine,  133 

natural  cure  of,  133 
treatment  of,  133 
torticollis,  646 
Rhachitis,  486 
etiology  of,  486 
foetal,  492 
prognosis  of,  490 
symptoms  of,  487 

deformities  as,  487 
treatment  of,  491 

prevention  of  deformity  in,  492 
Rheumatic  gout,  274 
Rheumatism,  gonorrhoeal.    See  Gon- 
orrhoea! arthritis,  267 
Rheumatoid  arthritis,  279 
etiology  of,  282 
treatment  of,  282 
Ribs,  absence  of,  233 
Rice  bodies  in  tuberculous  joint  dis- 
ease, 253 
Rickets.     See  Rhachitis,  486 
late,  492 

scurvy.      See   Infantile    scorbutus 
494 
Rigid  weak  foot,  690 

treatment  of,  690 

forcible    overcorrection    in, 

690 
manipulation  in,  693 
varieties  of,  695 
treatment  of,  696 
operative,  697 

arthrodesis  in,  697 
plaster  strapping  in,  696 
Thomas,  696 


838 


INDEX. 


Roentgen  ray  as  nieans  of  diagnosis 
in  tuberculous  disease  of  spine,  65 

Rotary    lateral    curvature   of    spine, 
149^ 

Rudimentary  patella,  436 
treatment  of,  436 


SACRO-ILIAC  articulation,  injury 
of,  148 
Sacro-iliac  disease,  146 
diagnosis  of,  147 
prognosis  oF,  147 
sjanptoms  of,  146 
treatment  of,  147 
Scapula,  congenital  elevation  of,  228 
Sciatic  scoliosis,  145 
Sciatica,  deformitj-  secondary  to,  145 
Scoliosis.      See  Lateral  curvature  of 
spine,  149 
hysterical,  621 
treatment  of,  621 
Scorbutus,   284 
infantile,  494 
Scurvy,  284,  494 

Secondarjr  deformities  accompanying 
knock-knee,  564 
hvpertrophic       osteo-arthropathy, 
'499 
Septic  infection  in  tuberculous  joint 

disease,  253 
Shaffer  extension  shoe  in  treatment 

of  acquired  talipes  equinus,  800 
Shoes,  728 

in  treatment  of  weak  foot,  682 
Shoulder,   congenital   dislocation   of, 
472 
treatment  of,  472 
Shoulder-joint,    chronic    bursitis    at, 
469  ■ 
periarthritis  of,  468 
symptoms  of,  468 
treatment  of,  469 
recurrent  dislocation  of,  476 
treatment  of,  476 
operative,  476 
tuberculous  disease  of,  457 
pathology  of,  457 
prognosis  of,  460 
statistics  of,  457 

age  at  incipiency  of,  458 
symptoms  of,  458 
treatment  of,  459 
operative,  460 
Slipping  patella,  436 
Snapping  finger,  483 
hip,  535 
knee,  438 
Socks,  732 
Spasmodic  torticollis.  See  Torticollis, 

spasmodic,  640 
Spastic  spinal  parah^sis,  616 
Spina  bifida  and  talipes,  793 
ventosa,  466 


Spina  ventosa,  statistics  of,  467 
Spine,  actinomycosis  of,  1.31 
acute  osteomyelitis  of,  130 
symptoms  of,  130 
treatment  of,  131 
anteroposterior  deformities  of,  224 
kyphosis,  224 

treatment  of,  227 
lordosis,  228 

treatment  of,  228 
contour  and  flexibility  of  normal, 

31 
divisions  of,  32 
hysterical,  143 
SA'mptoms  of,  143 
treatment  of,  144 
infectious  arthritis  of,  135 

treatment  of,  135 
injury  of,  131 
landmarks  of,  34 
lateral  curvature  of,  149 
cases  of,  167 
changes   in   anteroposterior 

contour  in,  155 
compensatory    deformity    in, 

165 
congenital,  167 
diagnosis  of,  175 
posture  in,  175 
mobility  in,  175 
due  to  occupation,  166 
etiology  of,  161 
hereditary  influence  in,  169 
high  hip  in,  156 

shoulder  in,  156 
incidental,  166 
lateral  deviation  in,  153 
occupation    as    inducing    de- 
formity, 170 
statistics  of,  170 
pathology  of,  156 
prevention    of    deformity    in, 

180 
prognosis  of,  177 
records  of,  177 
rhachitic,  168 

statistics  of,  169 
rotation  in,  153 
secondary   to   deformity   else- 
where, 165 
to  disease  within  thoracic 

walls,  166 
to  paralysis,  166 
statistics  of  age  in,  163 

of  relative  frequency  of,  161 
of  sex  in,  162 
symptoms  of,  174 
treatment  of,  181 
duration  of,  221 
exercises  in,  185-201 
Teschner's,  187 
muscle  building,  209 
forcible    correction   deform- 
ity in,  217 


INDEX. 


839 


Spine,  lateral   curvature  of,  treatment 
of,  general,  221 
high  shoe  in,  221 
posture  in,  185 
Volkniann  seat  in,  221 
varieties  of  deformity  in,  173 
Spine,  malignant  disease  of,  129 
diagnosis  of,  130 
statistics  of,  129 
neurotic,  142 

symptoms  of,  143 
treatment  of,  143 
osteo-arthritis  of.     See  Spondylitis 

deformans,  135 
rhachitic,  133 

natural  cure  of,  133 
treatment  of,  133 
rheumatism   of.       See    Spondylitis 

deformans,  135 
syphilis  of,  129 

diagnosis  of,  129 
tabetic  deformity  of,  142 
Spine,  tuberculous  disease  of,  17 
complications  of,  104 
abscess,  104 

in  different  regions,  106 
statistics  of,  104 
treatment  of,  108 
aspiration  in,  110 
injection  in,  110 
paralysis.  111 
duration  of,  114 
frequency  of,  112 
liability  to,  in  different  re- 
gions, 113 
local,  119 
prognosis  of,  116 
symptoms  of,  114 
time  of  onset  of,  113 
treatment  of,  116 
operative,  117. 

laminectomy,  118 
diagnosis  of,  46 
differential,  46 
congenital   dislocation   of 

hip,  47 
hip  disease,  48 
lumbago,  46 
sacro-iliac  disease,  46 
sciatica,  46 
in  general,  64 

Roentgen  ray  in,  65 
examination  in,  regional,  38 

tests  in,  37 
forcible  correction  of  the  de- 
formity of,  119 
Calot's  operation,  119 
selection  of  cases  for,  121 
gradual  correction  of  deform- 
ity of,  123 
Goldthwait's     method, 

123 
Metzger-Goldthwait  ap- 
paratus for,  123 


Spine,  tuberculous  disease  of,   history 
of  patient  having,  36 
later  effects  of  deformitv  of, 

127 
in  lower  region,  38 

characteristic  attitude  of, 

38 
increased  lordosis  in,  39 
lateral  inclination  of  body 

in,  40 
location  of  pain  in,  40 
pelvic  abscess  in,  44 
psoas  contraction  in,  40 
pathology  of,  18 
prognosis  of,  25 
record  of  the  case,  65 
recurrence  of,  127 
relative  frequency  of,  22 

statistics  of,  22 
secondary     deformities      of, 

127 
signs  of,  physical,  36 

rational,  35 
statistics  of  age  at  time  of  on- 
set of,  23 
results  of  Calot's  operation, 

120 
sex,  23 

situation  of  disease,  23 
symptoms  of,  26 
"  awkwardness  as,  28 
deformity  as,  28 
diagnostic,  27 
general,  31 
pain  as,  27 
secondary,  30 
abscess,  30 
paralysis,  30 
stiffness  as,  28 
weakness  as,  28 
thoracic  region,  51 
abscess  in,  55 
attitudes  in,  52 
diagnosis  of,  55 

differential,  56 
kyphosis  in,  54 
muscular  spasm  in,  54 
respiration  in,  52 
treatment,  66 

ambulatory  supports  in,  74 
anterior  shoulder   brace 

in,  76 
corsets,  95 
jury  mast,  86 
plaster  corset,  92 
plaster  jacket,  82 

modifications  of,  93 
Taylor  brace,  74 

head  support,  81 
Thomas'  collar,  96 
Weigel's  corset,  95 
duration  of,  126 
indications    for,  by    recum- 
bency, 98 


840 


INDEX. 


Spine,    tuberculous   disease  of,   treat- 
ment of  special  indications 
for,  of  different  regions,  99 
mechanical,   general   princi- 
ples of,  66 
horizontal  fixation  in,  67 
Bradford  frame,  68 

modifications  of,  69 
Lorenz    apparatus    for, 

67 
Phelps'  bed,  68 
wire  cuirasse,  68 
middle  cervical  region,  102 

region,  102 
occipito-axoid  region,  103 
upper  dorsal  region,  102 
\ipper  region,  57 

cervicodorsal  junction,  60 
diagnosis  of,  61 
lower   cervical   section, 

59 
occipito-axoid    section, 
58 
symptoms  of,  58 
Spine,  typhoid,  134 
treatment  of,  134 
A'ariations  in  contour  of,  223 
Splay  foot.    See  Weak  foot,  664 
Spondylitis  deformans,  135 
cases  of,  138 
pathology  of,  136 
symptoms  of,  138 
treatment  of,  141 
traumatic,  132 
treatment  of,  133 
Spondylolisthesis,  145 
Spondylose  rhizom^lique.    See  Spon- 
dylitis deformans,  135 
Spontaneous  dislocation  of  hip-joint, 

393 
Sprain  of  ankle,  450 
chronic,  453 

treatment  of,  453 
symptoms  of,  450 
treatment  of,  450 

adhesive  plaster  in,  451 
of  wrist,  470 
chronic,  470 
Sprengel's  deformity,  228 
cases  of,  229 
etiology  of,  229 
treatment  of,  229 
Statistics  of  abscess  complicating  tu- 
berculous disease  of  the 
spine,  104 
in  different  regions,  106 
in   tuberculous    disease    of    hip- 
joint,  371 
Koenig's,  372 
knee-joint,  419 
of  actual  lengthening  in  tubercu- 
lous disease  of  knee-joint,  408 
shortening    in    tuberculous    dis- 
ease of  knee-joint,  407 


Statistics  of  acute  arthritis  of  infancv, 
271 
age   at   incipiencj"   of   tuberculous 
disease  of   elbow-joint, 
461 
of  knee-joint,  402 
of  shoulder-joint,  458 
of  wrist-joint,  465 
in  lateral  curvattire  of  spine,  163 
at  onset  of  acute  anterior  polio- 
myelitis, 584 
of   patients   having   tuberculous 
disease  of  ankle-joint, 
441 
of  bones  and  joints,  247 
of  hip-joint,  295 
at  time  of  onset  of  tuberculous 
disease  of  spine,  23 
of  bow-leg,  553 

relative  frequency  of,  553 
table  of,  554 
Brackett's,  of  atrophy  in  tubercu- 
lous disease  of  hip-joint,  308 
of  causes  of  death  in  tuberculous 
disease     of      hip-joint, 
385 
of  knee-joint,  425 
of  Charcot's  disease,  285 
of  club-hand,  479 
of    congenital    dislocation    at    hip- 
joint,  502 
of  coxa  A^ara,  538 
of  deformity  resulting  from  tuber- 
culous disease  of  knee-joint,  425 
of  diseases  of  nervous  system,  583 
of  distribution  of  disease  in  tuber- 
culous  disease   of   bones   and 
joints,  246 
of    parah^sis    in    acute    anterior 
poliomyelitis,  585 
in  cerebral  paralysis  of  child- 
hood, 606 
Bollinger's,  of  retardation  of  growth 
in  tuberculous  disease  of  hip- 
joint,  311 
of  situation  of  tuberculous  dis- 
ease of  spine,  24 
of  excision  of  hip  in  tuberculous 

disease  of  hip-joint,  379 
of  final  results  of  excision  of  elbow, 
464 
in  tubercular  disease  of  knee- 
joint,  424 
of  frequency  of  paralysis  in  Pott's 

disease,  112 
functional  results  after  tuberculous 
disease  of  hip-joint,  387 
of  knee-joint,  424 
Gibney's,  of  course  and  outcome  of 
tuberculous  disease  of  knee-joint, 
423 
of  gonorrhoeal  arthritis,  267 
of  knock-knee,  553 

relative  freciuency  of,  553 


INDEX. 


841 


Statistics,  knock -knee,  table  of,  554 
of  malignant  disease  of  spine,  129 
of  inortality,  Koenig's,  in  tubercu- 
lous disease  of  knee-joint,  424 
in    tuberculous    disease    of    hip- 
joint,  384  _ 
occupation  as  inducing  deformity 
in  lateral  curvature  of  spine,  170 
of   open   operation   for   congenital 

dislocation  of  hip,  532 
of  relative  frequency  of   different 
forms  of  talipes,  742 
of  lateral  curvature  of  spine, 

161 
of  tuberculous  disease  at  dif- 
ferent vertebra?,  24 
of  hip-joint,  295 
of  spine,  22 
strength  of  muscles  of  foot,  659 
of  results  of  arthrectomy  in  tuber- 
culous  disease   of   knee-joint, 
421 
of  Calot's  operation,  120 
of   excision   in   tuberculous   dis- 
ease of  knee-joint,  423 
of  laminectomy  in  treatment  of 
Pott's  paraplegia,  118 
■   after-treatment    of    tuberculous 

disease  of  ankle-joint,  448 
rhachitic  lateral  curvature  of  spine, 

169 
of  sex  in  lateral  curvature  of  spine, 
162 
of  patients  with  tuberculous  dis- 
ease of  hip-joint,  295 
of  spine,  23 

of  bones  and  joints,  247 
of  side  affected  in  tuberculous  dis- 
ease of  bones  and  joints, 
246 
of  hip-joint,  296 
of  situation  of  disease  in  tubercu- 
lous   disease    of    ankle- 
joint,  441 
of  spine,  23 
of  spina  ventosa,  467 
table  of  age  at  incipiency  of  tuber- 
culous disease  of  ankle-joint,  442 
of  talipes,  741 

equinovalgus  with  congenital  ab- 
sence of  fibula,  790 
Taylor's,  of  retardation  of  growth 
in    tuberculous    disease    of    hip- 
joint,  312 
of  tendon  transplantation  for  relief 

of  paralytic  talipes,  815 
of  torticollis,  625 

of    tuberculous    disease    of    ankle- 
joint,  440 
elbow-joint,  460 
individual  bones,  449 
of  knee-joint,  401 
of  shoulder-joint,  457 
of  wrist-joint,  464 


Statistics  of  weak  foot,  669 
Strain  of  tendo  Achillis,  716 
Subacute  osteomyelitis,  273 
Subastragaloid  disease,  441 
Subcutaneous  tenotomy  in  treatment 

of  talipes,  772 
Subluxation  of  wrist,  478 
etiology  of,  478 
treatment  of,  479 
Synovial  tuberculosis  at  knee,  420 

treatment  of,  420 
Synovitis  of  knee,  427 
chronic,  428 

treatment  of,  428 
treatment  of,  427 
Syphilis  of  spine,  129 
diagnosis  of,  129 
Syphilitic  diseases  of  joints,  263 
gonorrhoeal  arthritis,  267 
distribution  of,  267 
statistics  of,  267 
symptoms  of,  267 
treatment  of,  268 
varieties  of,  268 
puerperal  arthritis,  269 
treatment  of,  265 


TABETIC  deformity  of  spine,  142 
Table  of  functional  results  after 
excision  of  hip,  380 
Table  of  weight,  height,  and  circum- 
ference of  chest  in  childhood,  235 
Talipes,  733 
acquired,  794 

development  of  deformity  in,  795 
differential  diagnosis  from  con- 
genital, 796 
etiology  of,  794 
arcuatus.    See  Contracted  foot,  699 
calcaneus,  acquired,  804 

development  of  deformity  in, 

804 
symptoms  of,  805 
treatment  of,  805 
operative,  807 

Whitman's  operation,  808 
Willett's  operation,  808 
congenital,  788 
Talipes,  congenital,  anatomy  of,  743 
etiology  of,  738 
symptoms  of,  748 
treatment  of,  748 
cavus.    See  Contracted  foot,  699 
equinovalgus,  789 
acquired,  813 

with  congenital  absence  of  fibula, 
790 
etiology  of,  791 
statistics  of,  791 
treatment  of,  792 
(iquiriovarus,  acquired,  812 

with  congenital  absence  of  tibia, 
792 


842 


INDEX. 


Talipes  equinus,  acquired,  796 
etiology  of,  797 
prognosis  of,  799 
sj'mptoms  of,  798 
treatment  of,  799 
arthrodesis  in,  803 
immediate  correction  of  de- 
formity in,  801 
tonic  effect  of,  801     ' 
Shaffer  extension  shoe  in,800 
Talipes,  etiologj-  of,  736 

forcible   manual   correction  of   de- 
formity of,  763 
infantile,    treatment    of,    Judson's 
brace  in,  754 
manual  correction  in,  760 
mechanical,  750 
plaster  bandage  in,  751 
principles  of,  749 
rectification   of   deformity   in, 

750 
retention  brace  in,  758 
splints  and  braces  in,  754 
Tajdor  brace  in,  758 
tenotomy  in,  756 
plantaris.   See  Contracted  foot,  699 
rapid   correction   of   deformity   of, 

763 
secondary  deformities  of,  770 
and  spina  bifida,  793 
statistics  of,  741 

relative    frequency    of    different 
forms  of,  742 
treatment  of,  division  of  the  tendo 
Achillis  in,  773 
open  method,  773 
malleotomy  in,  772 
by  method  of  Julius  Wolff,  774 
neglected,  761 

operations  on  the  bones  in,  781 
astragalectomy,  781 
cuneiform  osteotomy,  782 
operations  on  bones  in,  second- 
ary osteotome',  783 
by  osteoclasts,  778 
Grattan  method,  778 
Phelps'  operation,  778 
simple    mechanical    rectification 
of  deformity  in  walking  chil- 
dren, 783 
subcutaneous  tenotomy  in,  772 
by  Thomas'  method,  776 
by  wrenches,  776 
valgus,  simple,  acquired,  814 
varieties  of,  734 
varus,  congenital,  787 

with  congenital  absence  of  tibia, 
792 
Tarsus,  tuberculous  disease  of,  449 

treatment  of,  449 
Taylor  brace  in  treatment  of  infantile 
talipes,  758 
of  tuberculous  disease  of  spine, 
74 


Taylor  brace  in  treatment  of  tubercu- 
lous disease  of   spine, 
application  of,  77 
measurements  for,  76 
Taylor  head  support  in  treatment  of 
tuberculous  disease  of  spine,  81 
median  abduction  brace  in  treat- 
ment  of  tuberculous   disease  of 
hip-joint,  364 
method  of  traction  in  tuberculous 

disease  of  hip-joint,  329 
statistics  of  retardation  of  growth 
in  tuberculous  disease  of  hip,  312 
Tendo  Achillis,  division  of,  in  treat- 
ment of  talipes,  773 
strain  of,  716 
Tendon  splicing,  823 

and  arthrodesis,  824 
transplantation      in      combination 
with  other  procedures,  822 
relief  of  paralytic  talipes,  815 
the  operation,  820 

modifications  of,  821 
selection   of   muscles   for, 

817 
statistics  of,  815 
in   treatment   of   acute   anterior 
poliomyelitis,  602 
Tenosynovitis,  454 
acute,  at  wrist,  470 
chronic,  at  wrist,  471 
treatment  of,  455 
tuberculous,  455 
Tenotomy  in  treatment  of  infantile 

talipes,  756 
Teschner's  exercises  in  treatment  of 

lateral  curvature  of  spine,  187 
Thomas'  brace  in  treatment  of  knock- 
knee,  570 
of  tuberculous  disease  of  hip- 
joint,  339 
modifications  of,  343 
collar  in  treatment  of  tuberculous 

disease  of  spine,  96 
knee  brace  in  treatment  of  tubercu- 
lous disease  of  knee-joint,  414 
method  of  reduction  of  deformity 
in  tuberculous  disease  of  hip- 
joint,  342 
of  treatment  of  talipes,  776 
treatment  of  tuberculous  disease  of 
hip-joint,  338 
for  weak  foot,  696 
Tibia,  anterior  displacement  of.    See 

Congenital  genu  recurvatum,  434 
Toe-joint,  painful  great,  719 
Toes,  overlapping,  727 
Torticollis,  625 
acquired,  631 
causes  of,  633 
varieties  of,  631 
acute,  631 
I  etiology  of,  632 

I  symptoms  of,  633 


INDEX. 


843 


Torticollis,  acquired,  varieties  of  acute, 
treatment  of,  640 
congenital,  626 
etiology  of,  629 
pathology  of,  630 
Torticollis,    congenital,    diagnosis    of, 
635 
with  diphtheritic  paralysis,  646 
irregular  forms  of,  645 

cervical  opisthotonos,  646 
ocular,  646 
paralytic,  645 

pathology  of,  641 
psychical,  646 
rhachitic,  646 
spasmodic,  640 
etiology  of,  641 
prognosis  of,  642 
treatment  of,  642 

description   of   operation    for, 

643 
operative,  642 
statistics  of,  625 
treatment  of,  636 

by  manipulation,  636 
by  the  open  method,  637 
overcorrection   of   deformity   in, 

638 
by  subcutaneous  tenotomy,  637 
Traction  hip  splint    for    tuberculous 
disease   of   hip-joint, 
327 
application  of,  331 
straps   for   tuberculous   disease   of 
hip-joint,  329 
Traumatic  coxa  vara,  548 
in  adult  life,  551 
treatment  of,  550 
equino valgus,  814 
separation  of  the  epiphysis  of  head 
of  femur,  550 
Traumatic  spondylitis,  132 
treatment  of,  133 
valgus,  814 
Treatment   of   abscess    complicating 
tuberculous      disease 
of  spine,  108 
aspiration  in,  110 
injections  in,  110 
in    tuberculous    disease    of    hip- 
joint,  374 
exploratory  operation  in, 
376 
of  knee-joint,  420 
of  achillobursitis,  714 
of  acquired  calcaneovalgus,  812 
calcanoovarus,  812 
luxation  of  clavicle,  233 
talipes  calcaneus,  805 
oquinus,  799 
of  acute  acquired  torticollis,  631 
anterior  poliomyelitis,  595 
arthritis  of  infancy,  271 


Treatment  of  acute  epiphysitis  at  hip- 
joint,  392 
osteomyelitis  of  spine,  131 
of  anchylosis,  286 

forcible  correction  in,  288 
passive  motion  in,  288 
X-ray  in,  289 
of  anterior  bow-leg,  582 
of    anteroposterior    deformities    of 

spine,  227 
of  arthritis  complicating  infectious 
diseases,  269 
deformans,  397 
Bier's,    of    tuberculous    disease   of 

joints,  259 
of  bilateral  hip  disease,  369 
of  bow-leg,  558 
of  calcaneobursitis,  716 
of  cerebral  paralvsis  of  childhood, 

612 
of  Charcot's  disease,  285 
of  chondrodystrophia,  494 
of  chronic  sprain  of  ankle,  453 

synovitis  of  knee,  428 
of  club-hand,  481 
of    congenital    dislocation    at    hip- 
joint,  513 
of  shoulder,  472 
talipes,  748 
of  contracted  fingers,  484 

foot,  702 
of  coxa  vara,  545 
of    displaced    semilunar    cartilage, 

432 
of  displacement  of  peronei  tendons, 

727 
of  Dupuytren's  contraction,  485 
during  stage  of  recovery  of  tuber- 
culous disease  of  hip-joint,  363 
of  elongation  of  ligamentum  patel- 
lae, 438 
of  flat  chest,  230 
of    general    contractions   at   knee, 

439 
of  genu  varum,  578 
of  gonorrhoeal  arthritis,  268 
of  haemophilia,  283 
of  hallux  rigidus,  719 
valgus,  723 
A'arus,  721 
of  hammer-toe,  726 
of  hemiplegia,  612 
of  hysterical  scoliosis,  621 

spine,  144 
of  iliopsoas  bursitis,  396 
of  infantile  scorbutus,  495 

talipes,  750 
of    infectious    arthritis    of    spine, 

135 
of  knock-knee,  567 
of  lateral  curvature  of  spine,  181 
duration  of,  221 
exercises  in,  185-201 


844 


INDEX. 


Treatment  of  lateral  curvature  of  spine, 
exercises  in,  Teschner's, 
187 
for  muscle  building,  209 
forcible    correction    of    de- 

formitj^  in,  217 
general,  221 
high  shoe  in,  221 
posture  in,  185 
Volkmann  seat  in,  221 
malformations  of  knee,  435 
mechanical,  of  tuberculous  disease 
of  hip-joint,  327 
of    spine,    ambulatory    sup- 
ports in,  74 
anterior  shoulder  brace, 

76 
application  of,  in  recum- 
bency, 89 
jury  mast,  86 
plaster  corset  as,  92 
plaster  jacket  as,  82 
Taylor  brace  as,  74 
head  support,  81 
Thomas'  collar,  96 
Weigel's  corset  as,  95 
general  principles  of,  66 
horizontal  fixation  in,  67 
Bradford  frame  for, 68 
Lorenz  apparatus  for, 

67 
Phelps'  bed  for,  68 
wire  cuirasse  for,  68 
of  metatarsalgia,  710 
of  neglected  talipes,  761 
of  neurotic  spine,  143 
of  obstetrical  paralysis,  474 
operative,  of  tuberculous  disease  of 
ankle-joint,  447 
of  elbow-joint,  462 
of  shoulder-joint,  460 
of  osteo-arthritis,  279 
of  hip-joint,  397 
of  knee,  428 
of  osteomalacia,  497 
of  paralysis  complicating  tubercu- 
lous disease  of  spine, 
116 
operative,  117 
laminectomy,  118 
statistics,  results,118 
of  paraplegia,  614 
of  periarthritis  of  shoulder,  469 
of  pigeon  chest,  231 
of  plantar  neuralgia,  717 
of  prepatellar  bursitis  of  knee,  429 
of  pretibial  bursitis,  430 
of     pseudohypertrophic     muscular 

paralysis,  619 
of  recurrent  dislocation  of  shoulder, 

476 
of  rhachitic  spine,  133 
of  rhachitis,  491 
of  rheumatoid  arthritis,  282 


Treatment  of  rigid  weak  foot,  690 
of  rudimentary  or  absent  patella, 

436 
of  sacro-iliac  disease,  147 
of  sinuses  in  tuberculous  disease  of 

hip-joint,  375 
of  slipping  patella,  437 

operative,  437 
of  snapping  knee,  439 
of  spasmodic  torticollis,  642 
of  spondylitis  deformans,  141 
of  sprain  of  ankle,  450 
of  Sprengel's  deformity,  229 
of  subluxation  of  wrist,  479 
of  svnovial  tuberculosis  at  knee, 

420 
of  sj'novitis  of  knee,  427 
of  talipes  equinovalgus  with  con- 
genital absence  of  fibula,  792 
of  tenosynovitis,  455 
of  torticollis,  636 
of  traumatic  coxa  vara,  550 

spondylitis,  133 
of  traumatisms  at  hip-joint,  391 
of  trigger  finger,  484 
of    tuberculous    disease    of    ankle- 
joint,  446 
of  elbow-joint,  461 
of  hip-joint,  325 
of  joints,  256 

carbolic  acid  in,  258 
by  drugs,  257 
by  local  application,  258 
X-ray  in,  258 
of  knee-joint,  409 
of  shoulder-joint,  459 
of  spine,  66 

indications   for,    bv   recum- 
bency, 98 
special,    at    different    re- 
gions, 99 
lower  region,  100 

dorsal  region,  101 
middle  region,  102 

cervical  region,  102 
occipito-axoid  region,  103 
upper  dorsal  region,  102 
of  tarsus,  449 
of  wrist-joint,  465 
of  typhoid  spine,  134 
of  A^arieties  of  rigid  weak  foot,  696 
of  weak  foot,  682 
of  webbed  fingers,  483 
Trigger  finger,  483 
etiology  of,  483 
treatment  of,  484 
Tuberculosis  of  bones  and  joints,  243 
distribution  of  disease  in,  246 
statistics  of,  246 
age,  247 
sex,  247 

side  affected,  246 
etiology  of,  243 
local  predisposition  to,  245 


INDEX. 


845 


Tuberculosis  of  bones  and  joints,  mode 
of  infection  in,  243 
pathology  of,  248 
perforation  of  joint  in,  250 
latent,  243 

synovial,  at  knee,  420 
treatment  of,  420 
Tuberculous   disease   of    ankle-joint, 
440 
deformity  of,  443 
diagnosis  of,  444 
pathology  of,  440 
physical  examination  in,  443 
prognosis  of,  448 
statistics  of,  440 
age,  441 
results.  448 

situation  of  disease,-  441 
table  of  age  at  incipiency, 
442 
subastragaloid  disease,  444 
symptoms  of,  442 
treatment  of,  446 
operative,  447 
reduction   of   deformit}^   in, 
446 
of  astragaloscaphoid  joint,  449 
Tuberculous  disease   of  ell)ow-joint, 
460 
excision  of  elbow  in  treatment 
of,  464 
statistics  of  final  results, 
464 
pathology  of,  460 
prognosis  of,  462 
statistics  of,  460 

age  at  incipiency  of,  461 
symptoms  of,  461 
treatment  of,  461 
operative,  464 
reduction  of  deformitv  in, 
462 
Tuberculous  disease  of  hip-joint,  291 
abscess  in,  371 

significance  of,  373 
statistics  of,  371 
Koenig's,  372 
treatment  of,  374 

exploratory  operations  in, 
376 
actual  lengthening  of  limb  in, 
313 
shortening  of  limb  in,  309 
in  adult,  371 
atroph}'  in,  307 

Brackett's  statistics  of,  308 
bilateral,  369 

treatment  of,  369 
changes  in  contour  of  hip  in, 

306 
comljined  with  disease  of  other 

parts,  370 
correction    of    deformity    by 
femoral  osteotomy,  382     . 


Tuberculous  disease  of  hip-joint,  de- 
formities   of      other     parts 
caused  by,  389 
details  of  1000  cases  of,  324 
diagnosis  of,  differential,  319 
anterior  poliomyelitis  in, 

319 
congenital   dislocation   of 

hip,  322 
coxa  vara  in,  321 

traumatic,  in,  321 
disease    of    bursse    about 

joint  in,  321 
epiphysitis  in,  320 
extra-articular  disease  in, 

320 
growing  pains  in,  319 
hysterical  joint  in,  322 
infectious  arthritis  in,  320 
local  injury  in,  319 
local  irritation  in,  319 
osteo-arthritis  of   the  hip 

in,  320 
Pott's  disease  in,  321 
rheumatism  in,  320 
sacro-iliac  disease  in,  321 
scurvy  in,  320 
synovitis  in,  319 
X-ray  as  means  of,  322 
distortion  of  the  limb  in,  301 
apparent  lengthening,  301 
shortening,  302 
etiology  of.    See  243 
examination    in,    method    of, 
313 
physical,  314 
excision  of  hip  in,  377 

Koenig's  method  of,  377 
statistics  of,  379 

table  of  functional  re- 
sults, 380 
general  symptoms  of,  313 
debilitv,  313 
fever,  313 
history  of  case  of,  313 
in  infancy,  370 
Koenig's  statistics  of,  304 
local  signs  of,  318 
measurements  of,  315 
method  of  estimating  degree  of 
distortion   of   limb 
in,  316 
Kingsley's  table,  318 
Lovett's  table,  316 
of  recording  case  of,  322 
formula  used,  323 
mortality  in,  statistics  of,  384 

causes  of  death,  385 
natural  cure  in,  303 
pathology  of,  291 
prognosis  of,  384 
as  to  fuiu'tioii,  387 
statistics  of,  387 
as  to  functional  results,  387 


846 


INDEX. 


Tuberculous  disease  of  the  hip-joint, 
reduction    of    deformity    in 
resistant  cases  of,  381 
relative  frequency  of,  295 

statistics  of,  295 
retardation  of  growth  in,  311 
Bollinger's    statistics    of, 

311 
Taylor's  statistics  of,  312 
sinuses  in,  375 

treatment  of,  375 
statistics  of  age  in,  295 
of  sex  in,  295 
side  affected,  296 
symptoms  of,  296 
limp  as,  298 
night  cry  as,  297 
pain  as,  297 
stiffness  as,  298 
treatment  of,  325 

application  of  plaster  spica, 

345 
during  stage  of  recovery,  363 
immediate  reduction  of  de- 
formity in,  348 
Judson's  perineal  crutch  in, 

365 
Lorenz's  spica  in,  347 
mechanical,  327 

application     of     traction 

splint  in,  331 
high  shoe  in,  331 
perineal  bands  in,  331 
splinting  in,  327 
Tavlor's  method  of  trac- 
tion in,  329 
traction  in,  327 
hip  splint  for,  327 
straps  for,  329 
by  plaster  bandage,  345 
practical    combination  trac- 
tion,    splinting,     stilting, 
356 
reduction   of   deformity   by 
Thomas'  method,  342 
bv    traction    brace    in, 

333 
by  weights  and  pulleys, 
350 
lateral  traction  in, 

353 
Marsh's    appliance 
for,  351 
relative  efficiency  of  traction 
hip  splint  in,  334 
and  splinting,  354 
Taylor's  median  abduction 

brace,  364 
Thomas',  338 
brace  in,  339 

modifications  of,  343 
Tuberculous    disease    of    individual 
bones,  449 
statistics  of,  449 


Tuberculous    disease    of     bones  'and 
joints,  241  -1     i^i 

arborescent  synovial,  252 
caries  sicca,  253 
diagnosis  of,  256 
lipoma  arborescens,  252 
other  forms  of,  251 
prognosis  in,  254 
repair  in,  254 
rice  bodies,  253 
septic  infection  in,  253 
treatment  of,  256 
Tuberculous  disease  of  knee-joint,;399 
abscess  in,  419 
statistics  of,  419 
treatment  of,  420 
actual  lengthening  of  limb  in, 
407 
statistics  of,  408 
shortening  of  limb  in,  407 
statistics  of,  407 
diagnosis  of,  408 
ctifferential,  408 

Charcot's  disease  in,  409 
haemophilia  in,  408 
hysterical  joint  in,  409 
infectious  arthritis  in,  409 
injiu'v  in,  408 
osteo-arthritis  in,  409 
rheumatisin  in,  409 
rheumatoid    arthritis    in, 

409 
sarcoma  in,  409 
sjmovitis  in,  408 
distortions  of,  primary    404 

secondary,  405 
etiology  of,  401 
operations  for  relief  of  final  de- 
formity, 423 
pathology  of,  399 
prognosis  of,  423 

statistics,   course,   and  out- 
come of,  423 
Gibney's,  423 
of  results,  424 
statistics  of,  401 

age  at  incipiency,  402 
symptoms  of,  402 
synovial  tuberculosis,  420 

treatment  of,  420 
treatment  of,  409 
accessory,  417 

Bier's  treatment  of,  418 
cautery  as,  417 
ichthyol  ointment  as,  417 
X-ray  as,  417 
amputation,  423 
arthrectomy  in,  420 
results  of,  421 
statistics  of,  421 
Billroth  splint  in,  413 
during  convalescence,  418 
excision  in,  422 
results  of,  423 


INDEX. 


847 


Tuberculous     disease    of     knee-joint, 
treatment  of,   excision  in, 
statistics  of,  423 
forcible  correction  by  reverse 

leverage,  412 
mechanical,  414 

caliper  brace  in,  417 
Thomas  knee  brace  in, 414 
operative    intervention    in, 

419 
plaster  bandage  in,  411 
reduction  of  deformity  in, 410 
traction  in,  412 
Tuberculovis  disease  of  shoulder-joint, 
457 
pathology  of,  457 
prognosis  of,  460 
statistics  of,  457 

age  at  incipiency  of,  458 

symptoms  of,  458 

treatment  of,  459 

operative,  460 

Tuberculous  disease  of  spine,  17 

abscess  in  different  regions,  106 
treatment  of,  108 
aspiration  in,  110 
injections  in,  110 
complications  of,  104 
abscess,  104 

statistics  of,  104 
paralysis,  111 
duration  of,  114 
frequency  of,  112 
liability  to  in  different  re- 
gions, 113 
prognosis  of,  116 
symptoms  of,  114 
time  of  onset  of,  113 
treatment  of,  116 
local,  119 
operati^•e,  117 

laminectomy,  118 
correction  of  deformity  of,  for- 
cible, 119 
Calot's  operation,  119 
selection    of    cases   for, 
121 
gradual,  123 

Goldthwait's     method, 

123 
Metzger    -    Goldthwait 
apparatus  for,  123 
diagnosis  of,  differential,  46 
congenital   dislocation   of 

hip  in,  47 
hip  disease  in,  48 
luniljago  in,  46 
sacro-iiiac  disease  in,  46 
sciatica  in,  46 
strain  of  back  in,  46 
in  general,  64 

Koen1g(!n  ray  in,  65 
examination  in,  njgional,  38 
tests  in,  37 


Tuberculous  disease  of   spine,  history 
of  patient  having,  36 
later  effects  of   deformity  of, 
127 
Tuberculous  disease  of  spine  in  lower 
region,  38 
characteristic  attitude  of, 

38 
increased  lordosis  in,  39 
lateral  inclination  of  body 

in,  40 
location  of  pain  in,  40 
pelvic  abscess  in,  44 
psoas  contraction  in,  40 
pathology  of,  18 
physical  signs  of,  36 
prognosis  of,  25 
rational  signs  of,  35 
record  of  the  case,  65 
recurrence  of,  127 
relative  frequency  of,  22 

statistics  of,  22 
secondary      deformities     of, 

127 
statistics  of  age  at  time  of  on- 
set, 22 
DoUinger's,  24 

of   relative   frequency    at 
different  vertebrae,  24 
of  results  of  Calot's  opera- 
tion, 120 
of  sex,  23 

of  situation  of  disease,  23 
symptoms  of,  26 
awkwardness  as,  28 
deformity  as,  28 
diagnostic,  27 
general,  31 
pain  as,  27 
secondary,  30 
abscess,  30 
paralysis,  30 
stiffness  as,  28 
weakness  as,  28 
Tuberculous  disease  of  spine,  thoracic 
region,  51 
abscess  in,  55 
attitudes  in,  52 
diagnosis  of,  55 

differential,  56 
kyphosis  in,  54 
muscular  spasm  in,  54 
respiration  in,  52 
treatment  of,  66 
duration  of,  126 
indications    for,  by    recum- 
bency, 98 
special,    of    different    re- 
gions, 99 
of  lower  dorsal,  101 

region,  100 
mechanical,  67 

ambulatory    supports    in, 
74 


848 


INDEX. 


Tuberculous  disease  of    spine,    treat- 
ment  of,    mechani- 
cal,anibulatory  sup- 
ports   in,    anterior 
shoulder  brace,  76 
corsets,  95 
plaster,  92 
Wiegel's,  95 
jury  mast,  86 
plaster  jacket,  82 
application    of,   in 

recumbency,  89 
modifications  of,  93 
Taj'lor  brace,  74 

head  support,  81 
Thomas  collar,  96 
general  principles  of,  66 
horizontal  fixation  in,  67 
Bradford  frame,  68 

modifications  of,  69 
Lorenz  apparatus,  67 
Phelps'  bed,  68 
wire  cuirasse,  68 
Tuberculous  disease  of  spine  of  middle 
cervical  region,  102 
of  middle  region,  102 

of  occipito-axoid  region,  103 
of  upper  dorsal  region,  102 
of  upper  region,  57 

cervicodorsal  junction,  60 
diagnosis  of,  61 
lower  cervical  section,  59 
occipito-axoid  section,  58 
s}-mptoms  of,  58 
Tuberculous  disease  of  tarsus,  treat- 
ment of,  449 
Tuberculous    disease    of    wrist-joint, 
464 
prognosis  of,  466 
statistics  of,  464 

age  at  incipiency,  465 
symptoms  of,  465 
treatment  of,  465 
Tumor  albus.     See  Tuberculous  dis- 
ease of  knee-joint,  399 
Typhoid  spine,  134 
treatment  of,  134 


u 


NILATERAL  knock-knee,  565 


YALGOCAVUS,  789 
Valgus,  simple  acquired,  814 
Valgus,  traumatic,  814 
Vertebrae,  absence  of,  230 
Volkmann  seat  in  treatment  of  lateral 
curvature  of  spine,  221 


WEAK  foot,  664 
anatomy  of,  664 
Weak  foot  in  childhood,  678 
symptoms  of,  678 


Weak  foot  in  childhood,  diagnosis  of, 
672 
etiology  of,  669 
extreme  types  of,  676 

persistent  abduction  in,  676 
pes  planus,  676 
irregular  forms  of,  680 
limitation  of  motion  and  muscu- 
lar spasm  in,  676 
pathologv  of,  668 
rigid,  690 

treatment  of,  690 

forcible    overcorrection    in, 

690 
manipulation  in,  693 
varieties  of,  695 
treatment  of,  696 
operative,  697 

arthrodesis  in,  697 
plaster  strapping  in,  696 
Thomas',  696 
Weak  foot,  statistics  of,  669 
symptoms  of,  670 
treatment  of,  682 
attitudes  in,  683 
brace  in,  685 

construction  of,  685 
exercises  in,  684 
shoe  in,  682 
support  in,  684 
varieties  of,  675 
Webbed  fingers,  482 
etiology  of,  483 
treatment  of,  483 
White  swelling.   See  Tuberculous  dis- 
ease of  knee-joint,  399 
Whitman's  operation  in  treatment  of 

acquired  talipes  calcaneus,  810 
Willett's    operation    in   treatment    of 

acquired  talipes  calcaneus,  808 
Wire  cuirasse  for  horizontal  fixation 

in  treatment  of  Pott's  disease,  68 
Wolff's  law,  235 

treatment  of  knock-knee,  574 
Wrist,  acute  tenosynovitis  at,  470 
chronic  tenosynovitis  at,  471 
congenital  deformities  at,  479 
-joint,  tuberculous  disease  of,  464 
sprain  of,  470 
chronic,  470 
subluxation  of,  478 
etiology  of,  478 
treatment  of,  479 
tuberculous  disease  of,  464 
prognosis  of,  466 
statistics  of,  464 

age  at  incipiency,  465 
symptoms  of,  465 
treatment  of,  465 
Wryneck.    See  Torticollis,  625 


X 


RAY  as  accessory  in  treatment 
of  tuberculous  disease  of  knee- 
joint,  417 


RD731 


W59 

19C3 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  731  W59  1903  C.1 

A  treatise  on  orthopedic  surgerv 


2002311690 


1  -^^'^i^Hii;:^- 


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